You are called to the ED to see a 78 year old man with new shortness of breath. For the last couple of months his wife claims that he can only walk from one end of the house to the other but this afternoon his dyspnoea got far worse.

A routine ECG is performed.

What abnormalities does this ECG show and what are the potential causes?

ST elevation in V2, V3

Inferior Q waves with flat t waves

A STEMI is called by ED but DDx are;

LV aneurysm,

pericarditis,

early repolarisation,

Brugada syndrome,

LBBB,

LVH

and raised ICP to name a few.

For more detail on causes of ST elevation see this page on causes of ST elevation

His urgent CXR looks like this

R sided effusion

You are a bit suspicious about the lack of chest pain and the acute on chronic nature of the dyspnoea. Of course to further elucidate the nature of these right lower zone and those ECG changes you grab the ultrasound

What do the chest ultrasound images suggest?

Right sided mild to moderate pleural effusion.

The second loop shows the underlying lung with a B-pattern arising from an uneven visceral pleural line. The remaining lung did not show a similar pleural line.

This could be consistent with lobar pneumonia but may also represent malignancy or pleural disease.

You want to assess the LV and RV function, determine any regional wall motion abnormalities  and

Unfortunately his barrel chest and increasing distress make positioning difficult

You start with this subcostal view while he is being pulled up the bed.


What can you conclude from these limited images?

His LV function is not normal and appears globally impaired. The short axis view seems to show a dilated apex but you will need more views

Luckily he has surprisingly good views at his apex in between breaths

what does this show?

A homogenous large LV thrombus sits within a dilated aneurysmal left ventricular apex.

This off axis AP2C shows the LV thrombus that was probably a result of a previous MI and an akinetic apical LV aneurysm.  This is likely to account for his exertional dyspnoea over the past months but his acute SOB could have been triggered by a new community acquired pneumonia or worsening CCF.

He was placed onto anticoagulation and IV antibiotics but was adamant that he did not want any surgical intervention.

Read more on LV thrombus and intracardiac masses in these echopraxis posts.

 

Cover image: old mobile phones

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