Dyspnea on Exertion in a 46-Year-Old Man

par **ben lamine** Sam 04 Déc 2010, 13:52

ben lamine: Membre actif; Messages : 224
Date d'inscription : 29/08/2010
Age : 40
Localisation : tunisie
Emploi : médecin urgentiste

Message n°1

Dyspnea on Exertion in a 46-Year-Old Man

Message par ben lamine Sam 04 Déc 2010, 13:52

Background

A 46-year-old man presents to the emergency department with a 5-day history of progressively worsening breathlessness on exertion and mild, general flulike symptoms. He also complains about night sweats and an intermittent low-grade fever, both of which started about 2 weeks ago. On physical examination, the patient does not appear to be in any acute distress. His vitals signs are measured as a pulse of 89 bpm, blood pressure of 140/85 mm Hg, and a respiratory rate of 19 breaths/min. He is afebrile, with a temperature of 99.8°F (37.7°C). The chest examination reveals nothing out of the ordinary, and his cardiovascular and respiratory examinations, including auscultation, are unremarkable. The abdominal examination reveals no fluid thrill, shifting dullness, or bruit. The liver and the spleen are not enlarged. There are no palpable lymph nodes. Of note, there are multiple areas of hyperpigmentation, but otherwise the skin inspection is unremarkable; no hematomas, bruises, wounds, or scars are noted. ECG shows a sinus rhythm with a heart rate of 84 bpm, and the T waves are somewhat flattened in leads V1, aVL, and III, but they are otherwise unremarkable.

par **ben lamine** Sam 04 Déc 2010, 13:55

ben lamine

ben lamine: Membre actif; Messages : 224
Date d'inscription : 29/08/2010
Age : 40
Localisation : tunisie
Emploi : médecin urgentiste

Message n°2

Re: Dyspnea on Exertion in a 46-Year-Old Man

Message par ben lamine Sam 04 Déc 2010, 13:55

Significant laboratory findings include a white blood cell count of 9.1 x 10³/µL (9.1 x 10⁹/L; reference range, 3.5-8.8 x 10⁹/L), a platelet count of 429 x 10³/μL (429 x 10⁹/L; reference range, 140-350 x 10⁹/L), a C-reactive protein level of 91 mg/L (reference range, < 10 mg/L), a lactate dehydrogenase (LDH) level of 4.7 microkatals (µkat)/L (reference range, < 3.5 µkat/L), an erythrocyte sedimentation rate (ESR) of 30 mm/h (reference range, 1-12 mm/h), and a D-dimer of 2.2 mg/L (reference range, < 0.25 mg/L). A spiral computed tomography (CT) scan is performed, which shows no pulmonary embolism. It does, however, reveal the presence of a significant pericardial effusion (1 cm ventral x 2.5 cm dorsal) and a multilobular substernal mass occupying the anterior superior mediastinum that is about 2.5 cm in thickness and 7 cm in length, with high absorption. Additionally, the mediastinal lymph nodes are enlarged; some are as large as 2 cm in size. No other pertinent findings on spiral CT are reported.

par **ben lamine** Sam 04 Déc 2010, 13:59

ben lamine

ben lamine: Membre actif; Messages : 224
Date d'inscription : 29/08/2010
Age : 40
Localisation : tunisie
Emploi : médecin urgentiste

Message n°3

Re: Dyspnea on Exertion in a 46-Year-Old Man

Message par ben lamine Sam 04 Déc 2010, 13:59

An emergent bedside echocardiogram is obtained. The echocardiographic findings confirm the presence of pericardial effusion, without signs or symptoms of a cardiac tamponade; additionally, a retrosternal mass is detected (see video clips).
http://cme.medscape.com/viewarticle/732708?src=cmemp&uac=156362AG