Undifferentiated SOB case summary

This was a difficult case. On the one hand, the patient was febrile with SOB, evidence of consolidation on lung US and a small collapsing IVC on echo consistent with peripheral vasodilation or hypovolaemia. All this point to a diagnosis of pneumonia, dehydration and sepsis. 

L3 showed early signs of interstitial disease (?infection) with an irregular pleura and B lines

However, the echo findings were not quite right. The LV and RV were not hyperdynamic as they should be in a septic patient. 

Example of a hyperdynamic heart

Also, using the 1:1:1 rule, with the LA as the reference, the RV and aorta seem slightly dilated

The dilated right side is more obvious on A4C where the RV appears 1:1 with the LV and there is slight septal bowing to the left side. And the RA is dilated. The flattening of the septum is also seen in PSAx. 

Given these inconsistent findings and the recent hospital admission, the patient underwent a CTPA. This showed a partially occlusive saddle PE (!) and L sided lobar consolidation. My take on this is that the IVC is small and collapsing because the patient had concurrent sepsis and hypovolaemia and the PE was not occlusive allowing flow around it, thus the pulmonary pressures were probably not very high. However, they were high enough to dilate the RV and RA acutely. 

If we had time, I would have done a DVT US as well. 

I am still not sure why his LV was not hyperdynamic, His ECGs remained normal and there was never any troponin rise. 

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