80 yr f thin built fever cough dyspnoea at rest.came to er rr40.bp140mmhg.spo2 room air 70only.admiteed rx with o2 bipap.nebu inj piptaz 4.5gm inj moxiflox.n tab clarithral.pt spo2 now 96on o2 4 litmin.rrstill 30 hr 140min.bedside echo not avialble.rx as cap.?chf.tlc 11200.sr creat2.sr na126.ddx n rx .



A case of pulmonary edema secondary to cardiac failure.. Because there is enlarged cardiac shadow with Fissural effusion and kerley B lines.. As fever is also there.. Associated consolidation should also be considered... Needs usg to find any pleural effusion associated.. . Very low spo2 also points towards a multiple aetiology.. Echocardiogram is needed if available.. Treat with diuretics and ace inhibitors with antibiotics for consolidation.. Send sputum for gram stain smear and culture and sensitivity

how can one explain unilateral findings only in acute pulmonary edema the earliest finding in acute pulmonary edema is cephalization which occur at PCWP if 10 to 12 which is way low for development of kersey b lines i agree there is unilateral fissure edema but can it have an alternate cause

Cephalisation (Upper lobes Vascular Redistribution) is a term applied only for CXR taken in erect(PA view) and full inspiration...with pcwp of 12 - 18mmhg representing Pulmonary venous Hypertension Above cxr is Ap view, in supine the gravity between the upper and lower zones are minimum...so one should look for Equalisation of vessels, which is normally present at hilar regions. So we should not Mis interpret in Ap view cxr's , if we find Kerley B lines and cephalisation is not visible, though Kerley B lines indicates pcwp of 18-25 mmhg .(so it's always better to compare with previous cxr's) In above cxr, even the Vascular pedicle is also not much enlarged which goes against CHF. So, it's mostly appearing like CAP as Consolidation(Air bronchogram visible in left para cardiac area) with parapneumonic effusion Is this pt having past h/o IHD and any other comorbid conditions which can be attributed to CHF as pneumonia can precipitate HF. What was her blood sugars on admission? But nothing is 100% true in medical science.Their are always exceptions. So, u can confirm it by simple Bedside USG Thorax (if available) to differentiate between Pulmonary edema and consolidation in this patient. 2D echo. Send NT-proBNP levels in case of dilemma Hyponatremia in this case can be due to SIADH as a result of Pneumonia .

You can add short course of vaptans in SIADH for hyponatremia

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Is the xray wrongly labelled or patient has situs inversus I think it looks like CAP with severe sepsis treatment is ok except I don't know about fluroquinilone and macrolide combination is recommended anywhere regarding heart failure in elderly patients can get precipitated by sepsis, mostly it is heart failure with preserved ejection fraction and needs diuretics only, BNP levels if possible can help otherwise trust your clinical decision

Sir, What is the evidence to say that it's HF with preserved EF in this case? Any points Favouring it?

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left sided isolated effusion is less common in heart failure, xray showing left sided effusion with consolidation do pleural tap treat as CAP this condition might have precipitated the heart failure if pt has prior weak heart, if no echo BNP will be helpful

cardiomegaly, bilateral + Fissural effusion, significant improvement with supplemental oxygen all goes more in favour of congestive heart failure. if you don't have echo machine but if you have very basic ultrasound with b mode only even then you are supposed to get LV contractility very easily which is very helpful.

Dextrocardia with pleural effusion left with pulmonary koch's, advised AKT.

??wrong labelling of sides ???situs invertus RMZ haziness fissural oedema...no need to give clarithromycin and moxifloxacin at a time kindly get an ecg and ABG done add furosemide 20 mg bd ct rest

In view of FEVER, TACHYPNOEA, LEUCOCYTOSIS, Diminished SpO2, a Diagnosis of a Lung Infection is more likely. Pulmonary Oedema can only be a D/D. Pls also consider that a combination of a Quinoline + Macrolide, although very good can have serious adverse effects in the

xray is mislabelled .....I think the aortic knuckle and the funds air is on the right side ......opposite shows effusion ....ecg 2 d echo Sr nt pro bnp and a diagnostic tapping

cardiomegaly Acute Pulmonary Edema Keeley B line Lt . Associated infection.Hyponatraemia

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