EMDoc

Archive for August, 2011|Monthly archive page

What is wrong with this CT?

In Uncategorized on August 2, 2011 at 11:02 pm

Here’s the scoop… The patient (aka the owner of this CT) is a 60yo M presenting to the ED with acute onset shortness of breath and dyspnea on exhaustion x3days. dyspnea with talking or walking 5 feet with dizziness, nausea and diaphoresis  . denies chest pain, syncope, or lower extremity swelling. Patient states he’s been monitoring his resting HR at home and they’ve ranged from 92-120’s.

PMHx – patient was recently diagnosed with bilateral DVT’s about 3months prior to this presentation. He declined anticoagulation therapy (due to personal beliefs – being a vegan, stating he won’t be compliant with the meds and generally refusing any long term medication therapy). Otherwise no medical history.

FHx – DVT and PE;

ROS – mild conversational dyspnea.
VS: 99.6, 117/82, 98, 18, 97% on RA. PE: patient is in no distress. No rales/rhonchi/wheezing on lung exam. No new murmurs in the heart. RRR. S1/S2. no LE edema. otherwise unremarkable.
DO WE REALLY NEED A CT TO MAKE THIS DIAGNOSIS?!!!!
Teaching Points: Prognosis of untreated non-massive Pulmonary Embolism!

Acute PE is divided into 2 categories – Massive (meaning the patient presents with hypotension – SBP<90mmHh) or Non-massive/submassive (meaning the patient is normotensive – SBP>90mmHg). Submassive PE’s are about 95% of the presenting cases of pulmonary embolism.

Remember your PERC rule Or Well’s criteria for evaluating low-risk PE patients. These rules help you calculate your pretest probability. However, dont forget to include your clinical picture and gestalt in the equation.
We can discuss these rules specifically in another TP but for this case, the PERC rule didnt apply since the patient didnt meet all 8 criteria; Based on Well’s criteria, this patient is at least a moderate-high risk of PE.
Rx.
Lovenox is generally prefered cause of its easier dosing (1mg/kg) however cant be used in patient with renal dysfunction
Heparin is also a choice.
tPa is usually reserved for patient with hemodynamic compromise.
CT read – multiple bilateral pulmonary embolism! Prognosis for this patient….not good (i’m still searching for a more scientific response, with percentages and all. :D)!
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