Internship case presentationMr. 69 years old ID: M100878741 Admission date: 94-08-11
Chief complaint
Present illness
69-year-old male Smoked 2 PPD for 25 years, but quitted 25 years ago COPD was diagnosed for 15 year with medical control Severe respiratory tract infection for several times Leg edema(+++) for 6 months Old TB Denied DM or HTN
Shortness of breath since 4 days before admission
Visited other hospital at first Tachycardia up to 190 beat/min
Impression: Af with CHF Insisted to discharge and came to our ER
In our ER ..Ambiguous complaints..
Shortness of breath
Bilateral legs edema (+++) Orthopnea for 6 months Cough with foamy whitish sputum
Chocking easily in recent days Intermittent fever for 2 months
Review of systems
General Condition: BW loss (-), FEVER (+/-), night sweating (-), cachexia (-), anorexia (-), MALAISE (+++)
Cardiovascular: palpitation (-), syncope (-), chest pain/tightness (-), ORTHOPNEA (+)
Pulmonary: hemoptysis (-), COUGH (+), nocturnal cough/wheezing (-), SPUTUM (+), SHORTNESS OF BREATH (++), CHOCKING (+)
Physical examination
General Appearance: acute ill looking severe respiratory distress
Cardiovascular: Inspection: visible apical pulse (-) Palpation: heave (-), thrills Percussion: cardiomegaly (-) Auscultation: S3 (-), S4 (-), murmur: nil No JVE
Chest: Breathing pattern: tachypnea (-), accessory respiration (-), paradoxical breathing (-), air hunger (-) Inspection: symmetric expansion Percussion: symmetric tympanic Auscultation: normal intensity, WHEEZING (+), fine crackles (-), coarse crackles (-)
Extremities: Cyanosis (-), ecchymosis (-), warm(+), LEG EDEMA (+++), varicose veins (-)
Lab data
CXR
Cardiac echo
Interpretation : 1. Tech. difficult study. 2. No chamber dilatation. 3. Adequate global LV performance. 4. Mild MR.
Impression
After admission..
Shortness of breath persisted Right chest pain Lung abscess formation
08/13 08/17
Lung abscess formation on 08/22
COPD with acute exacerbation could not explain patient’s severe respiratory distress….
CT was done, and ….
Pulmonary embolism was found No DVT of lower extremities was found The patient started to received intravenous heparin therapy….
To be continued..
First of all..
The great masquerader!! Annual incidence: 0.5 per 1000 in the Western world 3-month mortality rate: 17.5%
How to approach the patient as a rookie in the field of medicine?
Risk factors
Inherited thrombophila: part I, part II THROMB HAEMOST 1996 (Level 3)

Symptoms and signs
A structured clinical model for predicting the probability of pulmonary embolism The American Journal of Medicine 2003 (Level 3)



Image finding
A structured clinical model for predicting the probability of pulmonary embolism The American Journal of Medicine 2003 (Level 3)

Electrocardiogram
QR in V1 – an ECG sign associated with right ventricular strain and adverse clinical outcome in pulmonary embolism Eur Heart J 2003 (Level 3)
Blood gas
Diagnostic Value of Arterial Blood Gas Measurement in Suspected Pulmonary Embolism Am. J. Respir. Crit. Care Med 2000 (Level 3)

Biochemistry
Plasma D-dimers in the diagnosis of venous thromboembolism. Arch Intern Med 2002 (Level 3)
Echocardiography
RV hypokinesis, RV end-diastolic diameter >27 mm, or tricuspid regurgitation velocity >2.7 m/sec
Sensitivity of 56% Specificity of 90%
Value of transthoracic echocardiography in the diagnosis of pulmonary embolism: results of a prospective study in unselected patients Am J Med. 2001 (Level 3)
Spiral computed tomography
Normal and/or near-normal threshold Greater discriminatory power than V-P scanning to exclude PE
High probability threshold helical CT and V-P scanning had similar discriminatory power in the diagnosis of PE.
Ventilation-perfusion scanning and helical CT in suspected pulmonary embolism: meta-analysis of diagnostic performance Radiology 2005 (Level 1)
Ventilation-perfusion scan
High probability threshold Low sensitivity of 39.0% High specificity of 97.1%
Normal threshold High sensitivity of 98.3% Low specificity of 4.8%
Ventilation-perfusion scanning and helical CT in suspected pulmonary embolism: meta-analysis of diagnostic performance Radiology 2005 (Level 1)
Angiography
Spiral Computed Tomography Is Comparable to Angiography for the Diagnosis of Pulmonary Embolism Am. J. Respir. Crit. Care Med (Level 4)

Patients with symptoms:
(-)
Evaluation of risk factors: primary, secondary, previous history
CXR Other cause -oligemia -artery amputation -Hampton’s hump -Palla’s sign
EKG Other cause -S1 Q3 T3 -Qr in V1 -STpos V1
CBC BCS ABG
• Definite diagnosis other than PE • Low probability
• No definite diagnosis • Intermediate probability
• High probability
Treat the real problem May follow-up with highly sensitive tools
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spe↑ sen↓
• No definite diagnosis • Intermediate probability
• High probability
D-dimer ELISA
V/Q scan
(+)(-)
Treat as PEMay exclude PE and follow- up with cardiac echo
Symptoms aggravated during follow-up
Spiral CT or angiogram (+)(-)
Spe↑ Sen →
• No definite diagnosis • Intermediate probability
• High probability
D-dimer ELISA
V/Q scan
(+)(-)
Treat as PEMay exclude PE and follow- up with cardiac echo
Symptoms aggravated during follow-up
Spiral CT or angiogram (+)(-)
Something else
MRI may play an important rule in the future Spiral CT as the first line diagnostic tool Utility of lung scan and angiography
Thanks for your attention! ~ ~~

2.JVE?? …. JVE
….JVE ??..
Internship case presentation
Patient’s profile