Pulmonary Embolism case presentation (1).pptx

Medcin

1. A c ase of a cute onset b reathlessness Case presentation : Surg SLT Bharath S Nambiar Discussion : Surg Cdr Abhish Mohan

2. Contents 01 03 04 02 History C l i nical examination Investigations Treatment 05 Present status

3. Patient particulars 52 year old serving sailor Resident of Tamil Nadu Informant : Self & Colleague Reliability: Good

4. Chief Complaints Breathlessness × 3days Loss of consciousness on 8/7/24 at 0640hrs for 1-2 minutes

5. HOPI Dyspnea for the past three days Acute onset, exertional MMRC 2 No orthopnea/PND 01 episode of loss of consciousness for 1-2 minutes while climbing stairs of escalator at metro station which was preceded with breathlessness No h/o tonic clonic movements/ post ictal confusion No tongue bite, sphincter incontinence No h/o injury/ bleeding from orifices h/o calf pain rt 01 month back, spontaneous resolution

6. No h/o Chest pain/Palpitation/diaphoresis Fever/cough/sore throat/hemoptysis Headache/visual disturbances/ weakness of limbs Trauma to chest wall Loss of appetite/ weight loss

7. Past medical history No h/o DM/TB/HTN No h/o Asthma No similar incidents in the past

8. Personal history Alcohol consumption for the past 30 years (60 ml hard liquor daily ) Reformed smoker for last 15years Normal bowel , bladder movements Normal sleep cycle No h/o sudden weight loss

9. Treatment history Patient was taken to nearest civil hospital post LOC Inj Levetiracetam 500mg iv stat Discharged and brought to our hospital against medical advice

10. Summary 52 year old male,presented with acute onset breathlessness, 01 episode of loss of consciousness with a recent history of pain and swelling in the right calf Clinically he has tachycardia , tachypnea and desaturation with unremarkable systemic examination

11. General examination Patient was conscious, oriented to time place person Vitals : Temperature : 97⁰F Pulse : 116bpm Bp : 140/90 mmHg RR: 26/min Spo2 : 96% at room air No pallor,icterus,cyanosis,clubbing,lymphadenopathy, No pedal edema/ swelling of calf

12. Systemic Examination Respiratory system On inspection : B/l symmetrical chest,no drooping of shoulders,trachea central No visible scars,pulsation,dilated veins No use of external respiratory muscle

13. On palpation : All inspectory findings confirmed Symmetrical movements of chest No rib crowding On percussion : Resonant note in lung fields On auscultation : B/l vesicular breath sounds No adventitious breath sounds

14. Systemic examination CVS S1S2 heard,no murmurs RS Accessory musles of resp not in use Normal b/l vesicular breath sounds, no adv sounds P/A Soft and non tender CNS No neurofocal deficits,higher mental function normal

15. ECG Negative S wave in lead I Deep Q wave in lead III T-wave inversion (TWI) in lead III Troponin I negative S1 Q3T3

16. Chest X-ray Chest X-ray AP view Partial inspiration film Cardiomegaly present

17. 2D ECHO Right ventricle almost dilated equal to left ventricle McConnels sign positive TAPSE :17-18mm MPA no clot

18. D-Dimer D-Dimer : 8145ngFEU/ml

19. CT Pulmonary Angiogram Hypodense non-enhancing filling defects noted involving the distal right main pulmonary artery, right upper lobar artery and bilateral interlobar arteries. Hypodense filling defects also noted involving anterior and posterior segmental arteries of right upper lobe, anterior segmental artery of left upper lobe, subsegmental artery of apicoposterior segment of left upperlobe, right middle lobar artery, lingular segmental artery, posterior basal segmental artery of both lower lobes and anterior basal segmental artery of right lower lobe.

20. CT Pulmonary Angiography Bilateral Acute pulmonary thromboembolism involving distal right main pulmonary artery, right upper lobar artery and bilateral interlobar arteries , more pronounced on right side Dilated pulmonary Artery(more than diam of aorta) Prominent Right ventricle ansd Right atrium

21. CDFI Of Right lower limb Echogenic thrombus seen within distal 1/3rd of superficial femoral vein,popliteal vein and proximal 1/3rd of posterior tibial vein Chronic deep vein thrombosis of Right lower limb present

22. Investigations Homocysteine : Above 50 Vit B12 : 295.21pg/ml Folic acid : 6.31ng/ml

23. Treatment Inj LMWH 60mg S/c BD Inj Thiamine 500mg BD Tab Mecoba 1500ug OD Tab Folic acid 5mg OD

24. Present Status Patient comfortable No breathlessness Vitals: Temperature: 98⁰F Bp:128/86mmHg Pulse: 90bpm Spo2:98% Started on Apixaban