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Internship case presentation 指導老師 : 賴俊良主任報告 : 廖以莊

Patient s profile Mr. 林 69 years old ID: M100878741 Admission date: 94-08-11

Chief complaint Shortness of breath for 4 days

Present illness 69-year-old male Smoked 2 PPD for 25 years, but quitted 25 years ago COPD was diagnosed for 15 year with medical control Severe respiratory tract infection for several times Leg edema(+++) for 6 months Old TB Denied DM or HTN

Shortness of breath since 4 days before admission Visited other hospital at first Tachycardia up to 190 beat/min Impression: Af with CHF Insisted to discharge and came to our ER

In our ER..Ambiguous complaints.. Shortness of breath Bilateral legs edema (+++) Orthopnea for 6 months Cough with foamy whitish sputum Chocking easily in recent days Intermittent fever for 2 months

Review of systems General Condition: BW loss (-), FEVER (+/-), night sweating (-), cachexia (-), anorexia (-), MALAISE (+++)

Cardiovascular: palpitation (-), syncope (-), chest pain/tightness (-), ORTHOPNEA (+) Pulmonary: hemoptysis (-), COUGH (+), nocturnal cough/wheezing (-), SPUTUM (+), SHORTNESS OF BREATH (++), CHOCKING (+)

Physical examination Vital signs: T/P/R 36.5/80/20 BP 130/76 General Appearance: acute ill looking severe respiratory distress

Cardiovascular: Inspection: visible apical pulse (-) Palpation: heave (-), thrills Percussion: cardiomegaly (-) Auscultation: S3 (-), S4 (-), murmur: nil No JVE

Chest: Breathing pattern: tachypnea (-), accessory respiration (-), paradoxical breathing (-), air hunger (-) Inspection: symmetric expansion Percussion: symmetric tympanic Auscultation: normal intensity, WHEEZING (+), fine crackles (-), coarse crackles (-)

Extremities: Cyanosis (-), ecchymosis (-), warm(+), LEG EDEMA (+++), varicose veins (-)

Lab data Leukocytosis

Pre-renal azotemia Respiratory acidosis + metabolic alkalosis Hypercapnia

CXR Cardiomegaly(-) Lung edema(-) Hepatomegaly(-) Infiltration(-)

Cardiac echo Interpretation : 1. Tech. difficult study. 2. No chamber dilatation. 3. Adequate global LV performance. 4. Mild MR.

Impression COPD with acute exacerbation Hypercapnia

After admission.. Shortness of breath persisted Right chest pain Lung abscess formation

08/13 08/17

COPD with acute exacerbation could not explain patient s severe respiratory distress. Lung abscess formation on 08/22 CT was done, and.

Pulmonary embolism was found No DVT of lower extremities was found The patient started to received intravenous heparin therapy. To be continued..

Discussion 1. Diagnostic tools 2. Diagnostic algorithm

First of all.. The great masquerader!! Annual incidence: 0.5 per 1000 in the Western world 3-month mortality rate: 17.5% How to approach the patient as a rookie in the field of medicine?

Risk factors Inherited thrombophila: part I, part II THROMB HAEMOST 1996 (Level 3)

Symptoms and signs ㄨㄨㄨㄨ A structured clinical model for predicting the probability of pulmonary embolism The American Journal of Medicine 2003 (Level 3)

Image finding ㄨㄨㄨㄨ A structured clinical model for predicting the probability of pulmonary embolism The American Journal of Medicine 2003 (Level 3)

Electrocardiogram Role of the 12-Lead Electrocardiogram in Diagnosing Pulmonary Embolism Cardiology in Review 2005 (Level 2)

Electrocardiogram QR in V1 an ECG sign associated with right ventricular strain and adverse clinical outcome in pulmonary embolism Eur Heart J 2003 (Level 3)

Blood gas ㄨ Diagnostic Value of Arterial Blood Gas Measurement in Suspected Pulmonary Embolism Am. J. Respir. Crit. Care Med 2000 (Level 3)

Biochemistry Plasma D-dimers in the diagnosis of venous thromboembolism. Arch Intern Med 2002 (Level 3)

Echocardiography Diagnostic criteria: (RV strain) RV hypokinesis, RV end-diastolic diameter >27 mm, or tricuspid regurgitation velocity >2.7 m/sec Sensitivity of 56% Specificity of 90% Value of transthoracic echocardiography in the diagnosis of pulmonary embolism: results of a prospective study in unselected patients Am J Med. 2001 (Level 3)

Spiral computed tomography Helical CT Pooled sensitivity: 86.0% Specificity: 93.7% Normal and/or near-normal threshold Greater discriminatory power than V-P scanning to exclude PE High probability threshold helical CT and V-P scanning had similar discriminatory power in the diagnosis of PE. Ventilation-perfusion scanning and helical CT in suspected pulmonary embolism: meta-analysis of diagnostic performance Radiology 2005 (Level 1)

Ventilation-perfusion scan High probability threshold Low sensitivity of 39.0% High specificity of 97.1% Normal threshold High sensitivity of 98.3% Low specificity of 4.8% Ventilation-perfusion scanning and helical CT in suspected pulmonary embolism: meta-analysis of diagnostic performance Radiology 2005 (Level 1)

Angiography Spiral Computed Tomography Is Comparable to Angiography for the Diagnosis of Pulmonary Embolism Am. J. Respir. Crit. Care Med (Level 4)

Discussion 1. Diagnostic tools 2. Diagnostic algorithm

Patients with symptoms: Evaluation of risk factors: primary, secondary, previous history (+) Sudden-onset dyspnea; pleuritic pain; fainting; unilateral leg swelling (-) Gradual-onset dyspnea; orthopnea; fever>38; wheezing CXR spe sen Other cause -oligemia -artery amputation -Hampton s hump -Palla s sign EKG Other cause -S1 Q3 T3 -Qr in V1 -STpos V1 CBC BCS ABG Other cause Other abnormalities -not useful in PE Find out prob group Other diagnosis Definite diagnosis other than PE Low probability No definite diagnosis Intermediate probability High probability Treat the real problem May follow-up with highly sensitive tools NEXT PAGE

Sen Spe No definite diagnosis Intermediate probability D-dimer ELISA (-) (+) Search for other cause Follow-up with cardiac echo Sen Spe High probability (-) Spiral CT V/Q scan Spe Sen In this group (+) Treat as PE Spe Sen F/O for pul. HTN (-) May exclude PE and followup with cardiac echo Symptoms aggravated during follow-up (+) Treat as PE (-) Spiral CT or angiogram Angiogram: golden standard Spiral CT: as sen. as angio. (+)

In this patient.. Sen Spe No definite diagnosis Intermediate probability D-dimer ELISA (-) (+) Search for other cause Follow-up with cardiac echo Sen Spe High probability (-) Spiral CT V/Q scan (+) Spe Sen Treat as PE Spe Sen F/O for pul. HTN (-) May exclude PE and followup with cardiac echo Symptoms aggravated during follow-up (+) Treat as PE (-) Spiral CT or angiogram Angiogram: golden standard Spiral CT: as sen. as angio. (+)

Something else MRI may play an important rule in the future Spiral CT as the first line diagnostic tool Utility of lung scan and angiography

Thanks for your attention! 呼 ~ 中秋節快樂 ~~

討論 1. 李宜恭主任 : 病人喘的原因?? Pulmonary embolism 可能是一個原因, 當有 thrombus 塞住血管時, 局部的支氣管會收縮, 使其他部份能有更多的通氣量, 使 V/Q match 一點, 所以也會有 wheezing 產生. 這是一種本能的 compensation, 所以用了 A+B 破壞這種反射, 反而可能使病人更喘.

2. 李宜恭主任 : 真的沒有 JVE 嗎??. 因為塞住的範圍不大, 所以也不見得一定會有 JVE 產生其實我是照急診記錄打的., 真的沒有 JVE 嗎?? 這個可能要問主任你自己比較知道喔..

賴俊良主任 : 其實這個病人不一定是 pulmonary embolism, 也有可能是當地原發的 thromboembolism, 定義很重要.. Lung abscess 的部份也有可能是 lung gangrene