A 63-year-old female with past medical history of COPD (on 2L home oxygen),

hypertension, “some remote heart surgery,” presents to the emergency department by EMS
with acute, increasing shortness of breath over the past 12 hours. Patient denies fever,
increased cough or recent travel.
Initial vital signs were HR 118, RR 35, SpO2 61% on 2L and BP 124/86. 
On physical exam the patient is alert and in severe respiratory distress, with diminished but
clear breath sounds bilaterally.

1. What is the diagnosis ?

a. Pericardial effusion
b. Pulmonary hypertension
c. Cardiomegaly
d. Pneumonia
e. Lymphadenopathy

2. What signs can be obtained from the diagnosis above?

a. Hillar enlargement
b. Elevated diafragma
c. Reverse comma sign
d. Infiltrate
e. Meniscus sign
A 42-year-old woman, with a medical history of diabetes mellitus and hypertension for 3 
years, was admitted to our hospital with chief complaints of generalised weakness, abdominal
pain and episodic shortness of breath. She was taking ramipril and hydrochlorothiazide for
hypertension and metformin and sitagliptin for diabetes mellitus. She denied chest pain,
fever, chills, diaphoresis or palpitations. On admission, her blood pressure was elevated at
202/117 mm Hg and her apical heart rate was 74 beats/min and regular. Family history was
non-contributory. She was afebrile and in no distress at the time of admission. Physical
examination was remarkable for lethargy. Heart sounds were distant; there was no gallop or
heart murmur. Bilateral leg oedema was present over the ankles and pretibial areas.

3. What is the diagnosis ?

a. Pericardial effusion
b. Pulmonary hypertension
c. Cardiomegaly
d. Pneumonia
e. Lymphadenopathy

4. What signs can be obtained from the diagnosis above?

a. Hillar enlargement
b. Elevated diafragma
c. Reverse comma sign
d. Double contour sign
e. Meniscus sign