|Miliary TB fig 1 |
|fig.2 cannonball metastases|
Fig 3: ....................
A 67-year-old female, former smoker came to an emergency with an increase in shortness of breath, abdominal distension, and leg swelling. She was managed with diuretics and was discharged from emergency observation on the next day. Basic investigations and echocardiography were done. she was managed in line with COPD and was discharged. She came to cardiology opd in the mid of the day just at the time to have a tea break. I was on a hurry. I saw her echo report which mentioned dilated RA, RV, and moderate TR. Assuming the diagnosis of COPD, I nearly dispatched the case. However, she had the use of her sternocleidomastoid muscles. On asking her symptoms, she had fatigue and exertional SOB for months and had a history of Pulmonary TB about 15 years back. when we saw her chest x-ray, we considered repeat echocardiography. my senior took her to the echo room and did an echo on her. He found the features suggestive of constrictive pericarditis. The pericardial calcification in a chest x-ray is highly suggestive of constrictive pericarditis. besides, when the edema is less prominent in right-sided heart failure symptoms, ascites praecox is a possibility. So, don't see a patient in a hurry.
fig.4 : right middle zone consolidation
A recently retired old man, smoker with no other past comorbidities came to OPD with a history of right-sided pleuritic chest pain for 2 days. No history of fever. He had a dry cough at that time. However, he gave a history of right leg swelling. basic investigations are done. Complete blood count, renal function, liver function were normal. He was prescribed antibiotics after seeing the very X-ray chest. what did we miss here?
The right leg swelling should have been taken quite seriously. Unilateral swelling of the leg with chest pain should prompt the suspicion of thromboembolism.
venous doppler of the legs would be a better approach in such a case. he had no other features suggestive of pneumonia. No leucocytosis, no fever.
Remember, pulmonary embolism is a great masquerade in clinical practice. It can mimic heart failure , pneumonia in elderly populations.