Differential and definitive diagnosis? | Figure 1

ray007

Anesthesiology Resident

Differential and definitive diagnosis?

Patient present to ER with Chest pain, S.O.B, pulmonary congestion and pulmonary hypertension, also fatigue... O/e - when we palpitate the chest we found Thirl and on auscultation we found murmur. ... what is your differential and definitive diagnosis?

Review Aim

To evaluate evidence on the ability of echocardiography to identify pulmonary hypertension in adults compared to right‐heart catheterisation.

Main Results

We found 17 studies involving 3656 people who had suspected pulmonary hypertension. There was a lot of variation in the studies. We found the characteristics of participants varied in terms of age, sex, cause of pulmonary hypertension, setting, and country. The cut-offs for the echocardiography readings chosen to diagnose pulmonary hypertension also varied. We used the available data to estimate how well echocardiography performed compared to right-heart catheterisation. In tertiary care hospitals, where most of the included studies were conducted, it is assumed that 680 of 1000 patients have pulmonary hypertension. We found that 592 out of 1000 would be correctly diagnosed with pulmonary hypertension using echocardiography. But 45 out of 1000 patients would be wrongly considered as having pulmonary hypertension (false positive), while 88 out of 1000 patients might be incorrectly considered as not having pulmonary hypertension (false negative) and 275 out of 1000 patients would avoid unnecessary referral for a right-heart catheterisation. In a scenario where the preoperative examination for liver transplantation is conducted, 100 of 1000 are assumed to have pulmonary hypertension. We found the number of false negatives and false positives would be 13 and 126, respectively.

Reliability of Results

We judged the included studies to have important limitations in their validity, which means that they were at high risk of providing distorted results. Therefore, we cannot be certain if the number of false negatives is correct (i.e. it could be even higher).

Applicability

These results apply to adults who are suspected of having pulmonary hypertension. However, the diagnostic accuracy of echocardiography varied considerably among studies and it is yet unclear what causes this diversity of test accuracy. Of note, the results are from studies conducted in relatively high prevalence settings. Therefore, care should be taken when applying this result to individual situations.

A 10-year-old female presented for a routine check-up. Can anyone guess what we found?

What do you think guys? 61yo male with a history of pulmonary TB and aspergillosis of the lung s/p VATS procedure. Side note - listening to the comparison of the left vs. right chest is pretty amazing.

Axial contrast enhanced CT of the chest shows a pulmonary sling. The main pulmonary artery (red *) gives rise only to the right pulmonary artery (blue *). The left pulmonary artery (arrowhead) arises from the right pulmonary artery. It courses between the trachea (anterior) and esophagus (posterior). If an upper GI was performed, we would see an anterior indentation on the esophagus at this level. #ThoraxThursday

A 52-year-old man presented with a 20-minute history of chest pain radiating to the left shoulder and neck, associated with dyspnea and diaphoresis. He had a history of hypertension, long-term smoking, and a sedentary lifestyle. On physical examination, bibasilar crackles were noted on lung auscultation. An electrocardiogram (ECG) was performed in the primary care setting, and the patient was promptly referred to the emergency department.

A 28-year-old woman presented with a 3-day history of intense pruritus over the lower back. She reported no recent travel or exposure to new environments. She cares for a small kennel with approximately eight dogs rescued from the streets. Physical examination revealed multiple small vesicles, some clustered and others scattered, predominantly involving the lumbar region and the left gluteal area.

A 4-month-old male infant presented with skin lesions localized to the chin for the past 3 days. Physical examination revealed multiple small pustules with surrounding inflammatory signs on the chin, along with a few scattered papules on the chest.

Patient in late teens presenting after a collapse, no chest pain, no previous cardiac history, no history of sudden death in family. Are there any features in this EKG that would warrant further work-up or is this just a pediatric EKG?