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Clinical Skills Challenge - case study 3

  • 9 Comments

THE COMPETITION FOR THIS CASE STUDY IS NOW CLOSED. THE ANSWERS ARE AT THE BOTTOM OF THE PAGE.

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.

Click here to download a printable PDF of this article (recommended)

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.

On admission:

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

 

Blood Pressure

90 / 50 mmHg
Pulse rate105 (regular)
Respiratory rate22 per minute
Tympanic Temperature37.2C
SaO289% on 4 litres of oxygen
Random blood glucose12.1. mmols/L

Table 2: Blood results

TESTRESULTREFERENCE RANGE
U&E’s  
Sodium138136-144
Potassium4.23.5-5.0
Chloride10095-105
Urea8.63.0-8.3
Creatinine12480-130
Haematology  
Haemoglobin174120-160
Mean Cell Volume8780-98
White Cell Count15.64.0-11.0
PT1310-14
PTT3226-36
Fibrinogen4.31.5-4
D dimer2816<250

Table 3: Results from arterial blood gas sample taken from radial artery

TESTRESULTREFERENCE RANGE
pH7.487.35 - 7.45
PCO23.94.65 - 6.0 kilopascals
Standard bicarbonate2524 - 32
PO29.611.5 - 14 kilopascals

Echocardiogram

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:

  • The clinical presentation is not entirely typical although some of the vital signs and observations would raise suspicions.

  • The d dimmer is significantly elevated suggesting that clot breakdown is occurring.

  • The ABG confirms hypoxia and a respiratory alkalosis.

  • 9 Comments

Readers' comments (9)

  • I would suggest a pulmonary embulus

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  • possible P.E. commence treatment anti -coagulant therapy ,V.Q Scan for diagnosis

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  • my thoughts are that this gentleman is suffering from a possible pulmonary embolism. anti coagulant therapy should be commenced a V Q scan performed. anti embolism stockings insitu and close monitoring of observations carried out . possible 02 therapy commenced in view of his low 02 saturation levels.

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  • may be ? PE due to recent flight, need referal to hospital for assessment,ie bloods,clexine,ted wt monitor.

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  • Pulmonary Embolus will need CTPA to confirm clot, anti-coagulant therapy to start immediatley. Regular bloods including INR levels. Neurological observations monitored. Oxygen therapy to commence as he is hypoxic.TEDS Stockings. Blood sample to check for diabetes and health education as he is overweight.

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  • I believe this man has a pulmonary embolism I suggest a CT scan of the chest to determine the answer and treatment withn anticoagualnt therapy hospital admission administration of oxygen and cardiac monitoring

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  • This gentleman most likely has a Pulmonary Embolism based on echo, he would need further investigations with CTscan/VQ scan whilst simultaneously undergoing prophylactic anticoagulation until definitive diagnosis i.e. low molecular heparinisation followed by warfarin once Dx confirmed. He would require symptomatic treatment - Oxygen therapy, monitoring for increased chest pain - morphine as required which would help with anxiety, monitoring of ECG changes indicative of infarction, monitoring of neurological signs and symtpoms of CVA, on going monitoring of biochemistry/haemotology/INR and arterial blood gases, application of antiembolic stockings and treatment of elevated BGL. REassurance and explanation of care and care choices/wishes. Part of discharge planning should include referal to endochronologist or diabetes nurse consultant and deitician for healthy eating and weight management to treat chronic health issues. Would also benefit from education re care during lengthy flights - get up and walk about plan, use antiemolic stockings.

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  • Initial clinical impression - exclude pulmonary embolus.
    Obsevations show decreased oxygen saturations which is worrying considering this gentleman has never suffered with any breathing problems before this episode.
    His blood chemistry also indicates that his D-dimer is quite elevated which is indicative of pulmonary embolus.
    His blood gases show that he is hypoxic and his PH is increasing ?metabolic compensation.
    Treatment - would need thrombising and then commencing on treatment dose of tinzaparin, would also need oxygen therapy (100%) as has no predisposing chest problems such as COPD.
    List for spiral CT scan or nuclear medicine to confirm diagnosis.

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  • How come respiratory alkalosis, the Po2 is so low.

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