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This 49-year-old gentleman was seen by his GP 3 days ago with shortness of breath on exertion. This was causing him to rest after walking 10 - 15 metres, having previously had no problems with exercise. He had no chest pain or cough. He had taken a flight back to Scotland from Los Angeles in late October 2007.
The man is overweight at 130kg and measures 180cm in height. His GP felt that this was a viral illness but referred him to the hospital when the symptoms were not improved 3 days later. He was admitted to Hospital mid December 2007.
He is quite uptight and is tachypnoeic and sweating. His JVP was not seen. He had no evidence of calf tenderness or swelling. He has evidence of peripheral cyanosis
Table 1: Vital signs on admission
|90 / 50 mmHg|
|Pulse rate||105 (regular)|
|Respiratory rate||22 per minute|
|SaO2||89% on 4 litres of oxygen|
|Random blood glucose||12.1. mmols/L|
Table 2: Blood results
|Mean Cell Volume||87||80-98|
|White Cell Count||15.6||4.0-11.0|
Table 3: Results from arterial blood gas sample taken from radial artery
|pH||7.48||7.35 - 7.45|
|PCO2||3.9||4.65 - 6.0 kilopascals|
|Standard bicarbonate||25||24 - 32|
|PO2||9.6||11.5 - 14 kilopascals|
An echocardiogram was requested and the following report was obtained:
‘The echocardiogram is poor image quality. The left ventricle is not dilated and there is no obvious left ventricular impairment. The right ventricle is moderately dilated with impaired function. There is a large amount of thrombus in the right ventricle apex. The right atrium is mildly dilated.
No obvious abnormality was noted on his chest x-ray. His admission 12-Lead ECG is shown in Fig 1 (See PDF of this article).
Answers to this case study
The diagnosis is Pulmonary Embolism (PE).
The main features are that this patient is hypoxic. He has evidence of cyanosis, his oxygen saturation is low and his arterial blood gas PO2 confirms these findings.
A number of factors would point you to this diagnosis: