Pulmonary Embolism

A Case of Pulmonary Embolism; Medical Student’s Experience

By: Muhamad Na’im B. Ab Razak

Medical student of University Science of Malaysia

Case Summary

53 Years Old Malay Lady who was recently discharge from ward with problem list of morbid obesity, uncontrolled diabetes mellitus, hyperlipidaemia and hypertension presented to emergency department with the chief complaint of sudden onset severe shortness of breath associated with central pleuritic chest pain and diffuse sweating.

She was alert and oriented to the time, place and person. Her blood pressure was 180/88 mmHg, heart rate was 120 b.p.m and respiratory rate was 20 breath per minute.

Full blood count, Renal Function Test were inconclusive. Cardiac biomarkers were not elevated, D Dimer was >5000 ng/ml.

ECG shows classical feature of Pulmonary embolism which are tachycardia, Deep S wave in lead I, Deep Q wave in lead III and inverted T wave in lead III (S₁Q₃T₃)

ABG under high flow mask of 100% oxygen, 10 L/min showed pH of 7.4, PCO₂ 28.6 mmHg, PO₂ 131 mmHg,HCO₃^- 19.6 mmol/L. Calculated Alveolar-arterial gradient (A-a gradient) was 190 which suggestive of V/Q mismatch.

A diagnosis of Pulmonary embolism was made based on high index of suspiciousness in risk factor, clinical presentation, ECG findings and A-a gradient. Therefore, CT Angiography was done and showed feature of extensive pulmonary embolism.

IV streptokinase 250 000 unit stat was commenced and followed with Streptokinase IV infusion 500 000 unit in 50 ml normal saline and patient was transferred to Cardiology Care Unit for further management.

ECG of the patient

contrast enhanced CT angiography of the patient

for discussion on pulmonary embolism and pdf version of this case, please download it [here]

Chronic Kidney Injury

Puan WNWY, 46 years old Malay lady with known history of renal impairment was brought to ED by her family after an episode of loss of Consciousness. On arrival, she already regains her consciousness but drowsy and confused.

On further questioning, her family said that she starts develop dizziness since three days ago associated with lethargy and loss of appetite. She was recently discharge from hospital after defaulting peritoneal dialysis.

There is no history of shortness of breath and chest pain.

On examination, the patient is ill- looking woman with sallow-face appearance. There is systolic murmur on auscultation of the heart but the lung fields are clear. There is no ankle edema noted.

BP: 214/ 82

PR: 123 bpm

T: 37⁰ C

Glucose level: 9.2 mmol/L

A full blood count, BUSE and ABG was ordered. While waiting for the result, IV line is set on patient left dorsum of the hand but IV drip is not giving due to kidney problem.

Result of FBC

WBC: 6.1 X 10⁹ L

RBC: 1.85 X 10¹² L

Hb: 5.5 g/dL (11.7-15.7)

HCT: 16.6% (37-47)

MCV: 89.7 fL

MCH: 29.7 pg

MCHC: 33.1 g/dL

Platelet: 127 X 10⁹/L

ABG result

pH: 7.05 (7.35-7.45)

pCO₂ : 16 (35-45)

pO₂ : 131 (75-100)

SO₂: 98%

HCO₃^- : 4mol/L (22-26)

BUSE

Urea: 46.3 mmol/L(2.5-7.5)

Na+: 139.1 mmol/L(135-145)

K+: 4.3 mmol/L (3.5-5.0)

Cl- : 111.8 mmol/L (98-107)

Creatinine: 1568.9 mmol/L (70-130)

Uric acid: 786.5 mg/dL (2.3-6mg/dL)

Clinical impression

1) Chronic Kidney Injury

2) Severe Metabolic Acidosis secondary to Chronic Kidney Injury

3) Hypertension

4) Cardiac problem? Need to rule out.

Management

1) Peritoneal dialysis is indicated

2) Admit patient to the ward

3) Restricted fluid intake.

4) Correct the acid base disturbance.

5) ECG and chest X-ray.

6) Manage the hypertension

Chest Infection in COPD patient

Puan RD 63 y.o malay woman with history of COPD presented to emergency department in Hospital Machang with shortness of breath and cough for one week duration.

The S.O.B is on and off and not relief by taking rest. The S.O.B is increase in intensity which brings her to ED. Meanwhile, the cough produces yellowish sputum. On further questioning, she is an ex smoker

BP: 120/80 (normal)

PR: 110 bpm (normal 60-80)

Temperature: 37⁰C

Approach to this patient.

1) This patient has acute exacerbation of shortness of breath due to COPD.

2) Nasal prong to give oxygenation. (nebulizer is not indicated)

3) Arterial blood gas need to be carried out.

4) Chest examination need to be performed

5) Full blood count is compulsory indicated by yellowish sputum. In elderly, fever usually not present in infection.

6) Chest infection needs to be ruled out due to history of COPD which predispose patient to chest infection.

7) BUSE

8) Take AP chest X-ray as patient is ill and cannot stand up properly. Mobile X-ray was called.

On physical examination

1) Reduce air entry to the left side of lung

2) Decrease lung expansion

3) Crackles on lower lung field.

ABG Result (on high flow mask)

pH: 7.37 (7.35- 7.45)

PCO₂ : 68 mmHg (35-45)

PO₂: 161 mmHg (75-100)

HCO₃- : 39 mmol/L (25-35)

1) This patient has type II respiratory failure in which pCO2 is high (oxygen high due to hi flow mask)

2) To correct this condition, respirator may be used to assist ventilation

Full blood count

WBC: 17.3 X 10⁹/L (4-11) with elevated neutrophil count

Hg: 13.4 g/dL

1) Elevated WBC indicates Infection.

BUSE result

Urea: 5.4 mmol (1.7-8.3)

Na⁺ : 138 (125-154)

K⁺ : 4.4 (3.5-5.4)

CL^- : 94.6 (98-108)

Creatinine: 56.6 µmol/L (53-100)

Uric acid: 393.2 µmol/L 9150-360)

AP Chest X-Ray

1) Hyperinflated lung

2) Visible hilar marking with peripheral opacity (not consolidation)

Management to this patient

1) Admit to the ward

2) Sputum culture

3) Antibiotics

4) IV fluid

5) Respirator to assist breathing.