Case Reports

Mild cough • wheezing • loud heart sounds • Dx?

Author and Disclosure Information

► Mild cough
► Wheezing
► Loud heart sounds


 

References

THE CASE

A 25-year-old man, who was an active duty US Navy sailor, went to his ship’s medical department complaining of a mild cough that he’d had for 2 days. He denied having any fevers, chills, night sweats, angina, or dyspnea. He said he hadn’t experienced any exertional fatigue or difficulty completing the rigorous physical tasks of his occupation as an engineman on the ship. The patient had no medical or surgical history of significance, and he wasn’t taking any medications or supplements.

On exam, he was not in acute distress and his vital signs were within normal limits. Auscultation revealed mild wheezing throughout the upper lung fields and loud heart sounds throughout his chest that were audible even with gentle contact of the stethoscope diaphragm. He had no discernible murmurs, rubs, or gallops.

Chest x-ray reveals normal-sized heart, but...

In light of the unusually loud heart sounds heard on exam, we performed an electrocardiogram. The EKG revealed a normal sinus rhythm, slight right axis deviation indicated by tall R-waves in V1 (also suggestive of right ventricular hypertrophy), an incomplete right bundle branch block, and a crochetage sign (a notch in the R-waves of the inferior leads).1 A chest x-ray (FIGURE 1) revealed a normal-sized heart and dilated pulmonary vasculature suggestive of pulmonary hypertension.

Echocardiogram reveals large atrial septal defect

Gated cardiac CT scan further elucidates the defect

THE DIAGNOSIS

To further evaluate the cardiopulmonary findings, ultrasound studies (transthoracic and transesophageal echocardiography) were performed. These demonstrated a very large secundum-type atrial septal defect (ASD), measuring at its largest point about 30 × 48 mm (FIGURE 2 and FIGURE 3C). Doppler flow analysis and a bubble study (VIDEOS 1 and 2) demonstrated significant shunting across the ASD. Gated cardiac computed tomography (CT) was also used to characterize the ASD (FIGURE 3). It revealed that the superior and posterior rims of the ASD were essentially absent and that the right atrium and ventricle were severely enlarged, while the left chambers were normal in size and function with an ejection fraction >55%. The notching of the R-waves of the inferior leads, seen in our patient’s EKG, is typically seen with large ASDs.1,2

VIDEO 1
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel.

Transthoracic echocardiography with color Doppler flow (red) demonstrated significant shunting across a large atrial septal defect (white box). The largest white dot is positioned near the center of the defect.

LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

VIDEO 2
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel.

Transthoracic echocardiography with a bubble study showed injected air bubbles traversing the atrial septal defect.

LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

Pages

Recommended Reading

U.S. influenza activity widespread to start 2018
MDedge Family Medicine
Atopic march largely attributed to genetic factors
MDedge Family Medicine
DMARDs may hamper pneumococcal vaccine response in systemic sclerosis patients
MDedge Family Medicine
Abstract: Antibiotic Prescribing for Nonbacterial Acute Upper Respiratory Infections in Elderly Persons
MDedge Family Medicine
Beware the COPD exacerbation
MDedge Family Medicine
Influenza: All that and MI too
MDedge Family Medicine
FDA approves starting dose of roflumilast
MDedge Family Medicine
CDC: Flu levels highest since pandemic year 2009
MDedge Family Medicine
Birth cohort affected 2015-2016 flu vaccine effectiveness
MDedge Family Medicine
States judged on smoking cessation services
MDedge Family Medicine