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Image of the weekJagdish K
Prof. Dr. A Gowrishankar’s unitm3
65 yr old male, who is a known smoker for the past 40yrs, presented with acute worsening of pre existing long standing breathlessness, 10 days prior to presentation
No h/o fever, cough or expectoration
h/O fracture neck of femur after trivial fall in bathroom 3years back and he was not ambulant since then.
O/E
◦ Pulse 110/min
◦ BP 130/80 mm of hg
◦ Conscious, oriented, afebrile
◦ Conjunctiva suffused
◦ CVS – S1 normal, P2 loud
◦ RS :B/L Wheeze+, Right base BS↓
◦ Other systems normal
Chest X ray
ECG
exudative
60 lymphocytes/cumm
6 mesothelial cells/cumm
Ada – 16 iu/l
Pleural fluid analysis
700ng/ml
D dimer
CT Chest
“ Few health care providers realise the case fatality rates for pulmonary embolism is 15%, exceeds that of acute MI”
Pulmonary embolism
Risk factors
Inherited
Acquired
Thrombophilias
Endotelial injury
Stasis
Hypercoagulablility
Virchow’s Triad
Most common symptoms & signs
Well’s clinical decision rule
Mild Moderate Severe Paradoxical Pulmonary infarction syndrome Nonthrombotic pulmonary embolism
Diverse clinical scenarios
Pulmonary infarction syndrome
Oxygen saturation
Chest x ray
D dimer
Investigations
ECG changes
Echocardiographic changes
Multidetector CT – The one stop shop
CT Angiography
CT PULMONARY ANGIOGRAM
Lung scanning
Pulmonary angiography
Venous ultrasound
MRI
continued
Clinical predictors of increased mortality
Biomarkers & imaging predictors of increased mortality
Approach to the patient
Lack of written diagnostic algorithm
Failure to use clinical probability scoring
Ruling out pulmonary embolism based on normal venous ultrasound of legs
Not evaluating after finding an abnormally elevated D- dimer test
Delay in seeking medical attention
5 common errors
“Can also occur concomitantly with other illnesses , thereby confounding the diagnostic work up”
“ The greatest challenges are to remember to consider the possible diagnosis of pulmonary embolism and realise that it can masquerade as many other illnesses”
THANK YOU