A 67-Year-Old Woman With Hypertension, Diabetes Presents With Shortness of Breath

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A woman presents to the emergency department with lethargy and marked shortness of breath.
A woman presents to the emergency department with lethargy and marked shortness of breath.

A 67-year-old woman with history of hypertension, insulin-dependent diabetes, and coronary artery disease presents to the emergency department shortly after being discharged from an outside hospital, where she was admitted for pyelonephritis complicated by cardiac arrest, according to her family.

After a week in the intensive care unit at the outside facility, she was transferred to a step-down unit and eventually discharged to a nursing facility. Little else is known about her care there. The family reports that her clinical status has been worsening since discharge. The nursing facility reported a history of congestive heart failure as communicated from the other hospital, but the family denies any hospitalizations for heart failure.

In the emergency department, the patient was found to be lethargic, with marked shortness of breath and oxygen saturations in the low 70s. Physical examination revealed a morbidly obese woman (body mass index 40) tachypnea (respiratory rate of 38), tachycardia with an irregular rhythm, bilateral rales, dry skin, and bilateral 3+ pitting edema. She is using accessory muscles, and jugular venous distention is present. Mean arterial blood pressure is 65 mm Hg. Electrocardiogram shows multifocal atrial tachycardia. Chest radiograph shows bilateral alveolar infiltrates. Blood gas measures reveal severe hypoxemia with respiratory alkalosis and elevated alveolar-arterial oxygen gradient. Other laboratory results show markedly high leukocytosis and lactate levels.

She is intubated in the emergency department for hypoxemic respiratory failure and started on empiric antibiotics with vancomycin and piperacillin/tazobactam. Once stabilized, she is transferred to the intensive care unit, where she is further stabilized.

What is the next best diagnostic imaging test?

A. Computed tomographic pulmonary angiography

B. Bedside transthoracic echocardiography

C. Bedside transesophageal echocardiography

D. Ventilation perfusion scan

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