Case description: 62-years old female enters the A&E. The reason of her visit is dyspnoea, which occurred this morning, when the patient went outdoor to open the poultry-house (this wasn't a big effort, but a patients everyday activity, which she used perform without any problems). The patient describes her complaint as shortness of breath, and clogged feeling. She has been feeling weak for a long time now, her legs hurt, but 2 weeks ago, the weakness slightly increased and the shortness of breath began to occur.
History: breast cancer, mastectomy 3 years ago. Patient is under constant care of an oncologist.
Abnormalities in physical examination:
Tachycardia (120/min)
crural varices
QUIZ questions:
What procedures do you order? What is the diagnosis and the treatment?
Comments
ECG
Heart USG
morphology
Patient has dyspnoea, but in the description of physical examination I don't see any auscultation and percussion abnormalities.
I'll wait for result of basic tests, because if we have nothing, guessing doesn't make sense...
But if I was House MD, I'd think about psittacosis.
RBC - 4,3 M/uL; HBG - 11 g/dl; MCV - 83 fl; MCH - 28 pg; MCHC - 34 g/dl; WBC - 5,2 K/uL; PLT - 480 K/uL
ECG:
sinus tachycardia
We can make heart USG tomorrow in our hospital.
The patient was asked about a contact with a parrot - denies ;-) except them chickens... :-)
pH 7,39; pO2 68mmHg; pCO2 41 mmHg; HCO3 24 mmol/l; SpO2 91%; BE 1,5 mEq/l
Electrolytes:
Na 139 mEq/l; K 3,9 mEq/l; Cl 101 mEq/l
Chest X-ray didn't reveal any abnormalities.
D-dimers - positive
Crural varices, slight oedema of right leg + hyperpigmentati ons and sclerosis of right ankle.
There aren't any indications of bronchofiberosc opy.
If big embolus occurs, acute symptoms direct us to appropriate diagnosis, but the emboli may be small and smaller vessels are obturated. Then it's possible to mistake it for, let's say, pneumonia
There weren't any abnormalities in auscultation .
Angio-CT was performed - a embolus in peripheral arteries was visualised. So dr Fisch was right - diagnosis is pulmonary embolism (non-massive). And exactly as dr Fish has written, symptoms don't have to occur suddenly.
After few hours, the patient's son brought a documentation. Earlier lab-tests' results, which the patient made in oncologist control and GP control, show increased d-dimers concentration in blood. Perhaps we have to deal with chronic pulmonary embolia. That condition can lead to right-heart overload and developing a pulmonary hypertension.
What is the treatment?
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