June 30, 2010

Pulmonary Embolism

A Case of Pulmonary Embolism; Medical Student’s Experience

By: Muhamad Na’im B. Ab Razak

Medical student of University Science of Malaysia

Case Summary

53 Years Old Malay Lady who was recently discharge from ward with problem list of morbid obesity, uncontrolled diabetes mellitus, hyperlipidaemia and hypertension presented to emergency department with the chief complaint of sudden onset severe shortness of breath associated with central pleuritic chest pain and diffuse sweating.

She was alert and oriented to the time, place and person. Her blood pressure was 180/88 mmHg, heart rate was 120 b.p.m and respiratory rate was 20 breath per minute.

Full blood count, Renal Function Test were inconclusive. Cardiac biomarkers were not elevated, D Dimer was >5000 ng/ml.

ECG shows classical feature of Pulmonary embolism which are tachycardia, Deep S wave in lead I, Deep Q wave in lead III and inverted T wave in lead III (S1Q3T3)

ABG under high flow mask of 100% oxygen, 10 L/min showed pH of 7.4, PCO2 28.6 mmHg, PO2 131 mmHg,HCO3- 19.6 mmol/L. Calculated Alveolar-arterial gradient (A-a gradient) was 190 which suggestive of V/Q mismatch.

A diagnosis of Pulmonary embolism was made based on high index of suspiciousness in risk factor, clinical presentation, ECG findings and A-a gradient. Therefore, CT Angiography was done and showed feature of extensive pulmonary embolism.

IV streptokinase 250 000 unit stat was commenced and followed with Streptokinase IV infusion 500 000 unit in 50 ml normal saline and patient was transferred to Cardiology Care Unit for further management.

ECG of the patient

contrast enhanced CT angiography of the patient

for discussion on pulmonary embolism and pdf version of this case, please download it [here]

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