HPI: – A 28-year Darrin, a white male patient came to ED c/o SOB for the last 2 hours and was admitted to the hospital. Started off with Cough and SOB on walking. Started Rt. Sided chest pain worsens with cough and deep breath. No relieving factors. Denies any fever, chills, malaise, and general weakness.
PMH: -R. flank pain with kidney stone 2 years ago Hernia repair at age of 6, nosebleed as a child and knee trauma. Mom diet at 50 with unknown cause, Dad is 58 with ischemic heart disease and CAD with CABG 2 yrs. ago, sister had multiple spontaneous abortions, positive family history of maternal grandfather died at 65 age following Abdominal surgery, nose bleeds and recurrent thrombophlebitis, chest pain, PE and was on coumadin.
Physical exam: – VS- HR-120, BP-120/80, TEMP-98.6, RR-30 shallow, Rhythm-regular, HT-7’3’’. Weight-150 lbs. Chest: Dullness to percussion at posterior right lung base and resonant to percussion otherwise.
Diagnostic tests to be ordered.
My differential diagnosis will be.
- Pulmonary embolism.
- CBC was within normal limits: To evaluate any infectious inflammatory cause which is evidenced by leukocytosis and presence of anemia or any platelet disorders. Leukocytosis is present in this patient can be of pneumonia, atelectasis, lung cancer, pulmonary tuberculosis. Sickle cell anemia may present with chest pain most prevalent in middle eastern and African descent populations. Since it is absent these conditions may be ruled out with other tests. In the later stage of pulmonary embolus, the patient may show up with leukocytosis.
- ABG: pH-7.49, PO2-60, pCO2-32, O2 sat 75%, Bicarbonate-25 nmol/L on RA. And on O2 100% pH-7.45, pO2-80, pCO2-35, O2 sat-85%, Bicarb-24 mEq/L. The patient has hypoxia and respiratory alkalosis, on room air and 100% Oxygen his hypoxia is corrected, and pH and back to normal. In PE because the part of the lung was affected with embolism, with possible lung infarction and that part of the lungs is not participating with air exchange make the patient, tachyonic, hypoxia leading to respiratory alkalosis. Respiratory worsening and relevant increase of D-dimer may enhance clinical suspect.
- Chest X-ray; Negative for infiltrates or other acute abnormalities.
- CT chest: Significance noted involving right lower lobe: Which is not confirmatory for the cause but can be suggestive of pulmonary embolus when you clinically correlate with patients’ symptoms and dullness in the right lung. According to Faggiano et al (2020), thrombosis of segmental/subsegmental arteries within lung infiltrates was occasionally seen on CT
- CT Chest spiral with PE protocol: There are intra-arterial filling defects in multiple vessels and segmental peripheral areas of consolidation (Lung infarcts) involving the right lower lobe. There are very confirmatory findings of right lower lobe filling defect in the intra-arterial in multiple vessels and area of consolidation in the diagnosis of pulmonary embolism in the right lower lobe.
- D-dimer: 850 ng/ml. Patients with pulmonary embolism usually have elevated D-dimer above 250ng/ml. This high level places the patient at high risk for any thromboembolic condition such as DVT and PE., stroke, or MI. This patient may have a clot in his lungs affecting his right lower lobe and probable infarction. A normal D-dimer level allows the safe exclusion of PE in outpatients with a low or intermediate clinical probability of PE (Bompard al, 2020)
- Covid-19: SARS COV: Which was not available.
- EKG Sinus tachycardia with occasional atrial premature contractions: This can be a finding in pulmonary embolus which causes stress to the heart causing tachycardia and atrial premature contractions. Right ventricular strain shows with sinus tachycardia and atrial arrhythmias is a common finding in PE (Thomson, Kourounis, Trenear, Messow, Hrobar, Mackay, & Isles, 2019).
- TEE (Transesophageal echocardiogram): Patients’ findings were normal position, size, and movement of the heart muscle, valves, and heart chambers. According to Bikdeli et al (2018), early TEE is commonly performed for acute PE, the right heart enlargement, right ventricular hypokinesis, and right heart thrombi are predictive of worse outcomes.
The primary diagnosis after diagnostic study is right lower lobe pulmonary embolism.
Bikdeli, B., Lobo, J. L., Jiménez, D., Green, P., Fernández‐Capitán, C., Bura‐Riviere, A., … & Quintavalla, R. (2018). Early use of echocardiography in patients with acute pulmonary embolism: Findings from the RIETE registry. Journal of the American Heart Association, 7(17), e009042. Retrieved from https://www.ahajournals.org/doi/full/10.1161/JAHA.118.009042
Faggiano, P., Bonelli, A., Paris, S., Milesi, G., Bisegna, S., Bernardi, N., … & Maroldi, R. (2020). Acute pulmonary embolism in COVID-19 disease: Preliminary report on seven patients. International journal of cardiology, 313, 129-131. Retrieved from https://www.sciencedirect.com/science/article/abs/pii/S016752732031901X
Bompard, F., Monnier, H., Saab, I., Tordjman, M., Abdoul, H., Fournier, L., … & Revel, M. P. (2020). Pulmonary embolism in patients with COVID-19 pneumonia. European Respiratory Journal, 56(1). Retrieved from https://erj.ersjournals.com/content/56/1/2001365.short
Thomson, D., Kourounis, G., Trenear, R., Messow, C. M., Hrobar, P., Mackay, A., & Isles, C. (2019). ECG in suspected pulmonary embolism. Postgraduate medical journal, 95(1119), 12-17. Retrieved from https://pmj.bmj.com/content/95/1119/12.abstract