Weekend Case Study 2

Created by:

24 Jul 2016 - General

55 years old gentlmean, with background medical history of hypertension, hypercholesterolaemia, and depression, was admitted due to 1 day history of gradual onset chest pain, and shortness of breath. He deny any productive cough, and no fever. He did noticed some change of bowel habit and unintentional weight loss recenlty. On examination showed that his oxgen saturation on room air was around 89%, respiratory rate of 20 per minute, BP -135/90, pulse 110, and temperature was apyrexia. Cardiovascular, respiratory, abdominal and neurology examination were normal. With regards to investigation, chest x ray was normal, blood test showed normal white cell count, neutrophil, CRP, with microcytic anaemia. ABG showed type 1 respiratory failure. What is your impression ?? What is the management and treatment strategy??? Any further investigation require?

Yes, pulmonary embolism (PE)will be the likely cause in this case cauing the symptoms. I would start low molecular weight heparin (either tinzaparin or enoxaparin) and get an urgent CT-PA for this patient. We should not do the D-dimer test in this case, as we are clinically highly suspicious of pulmonary embolism. IF confirmed pulmonary embolism on CTPA, should continue the low molecular weight heparin, and then introduce oral anticoagulation (can be either warfarin or direct oral anticoagulant)...
 (Total 117 words)
Pulmonary embolism will be top of the list since the findings of 1) Tachycardia 2) Type 1 respiratory failure 3 ) Normal chest x-ray 4) Chest pain
I will order an urgent computed tomography angiography immediately and lower limb doppler ultrasound, CHeck on the PT/PTT .
If confirm PE, start IV heparin and monitor aPTT. Switch to s/c enoxiparin once target reached. I am not very good at my antigoagulation please correct me if I am wrong. Consider insertion of inferior venous cava sieve, ...
 (Total 108 words)