saaid presented a case of an elderly gentleman [did we get his ethnicity? - see previous post] with a short-ish history of breathless, and a significant history of past PEs
we reviewed the aetiology of SOB, dividing them into hyper-acute, acute and chronic causes
an systematic division (cardiac, respiratory, chest wall, neurological, haematological etc) was also noted
we noted that diagnosis of PE is best based on a formal scoring system, eg wells & geneva, and that clinical features of PE & alternative diagnoses are part of the score [there are data showing the appropriate use of scoring leads to fewer repeat events, eg roy et al 2006]
this gentleman had emboli confirmed on CTPA
we briefly discussed investigation, in particular examination, CXR & ECG findings. we did not look at D-dimers or VQ scans - he was severely hypoxic but not retaining C02
we briefly discussed LMWH, warfarin, thrombolysis & embolectomy as therapies
[as an aside this gentleman had a troponin of 0.2 - is this significant?]
i mentioned the algorithm in davidson's 21e as being useful
as lessons, we raised the following issues, amongst others:
- presenting patients/summarising patients
- ABGs
- causes SOB
- NYHA classes
- investigation PE
as action points, we endeavored to:
- list causes aortic regurg
- find out how not to kill patients presenting with a sickle chest crisis
- improve our skills in ABG interpretation by finding a good learning resource & looking at patients' results
- find out if there is a NICE guideline on PE (i don't think so - the is a BTS guideline)
- review Dr Dilworth's lecture on SOB
- read various bits of Kumar & Clark, Baliga [not only is he a professor in ohio, he also has an MBA!]
- review Medicine at a Glance
- see more patients with PE
- follow up our patient
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He was Caucasian, I'm afraid I can't be more specific.
ReplyDeleteFull BTS guidelines on the management of an acute PE can be found at http://www.brit-thoracic.org.uk/Portals/0/Clinical%20Information/Pulmonary%20Embolism/Guidelines/PulmonaryEmbolismJUN03.pdf
ReplyDeleteWe were particularly interested in following up patients PE to identify an underlying cause. In regards to this it says:
"Testing for thrombophilia should be considered in patients aged under 50 with recurrent PE or in those with a strong family history of proven VTE."
Also, it says if no indication of malignancy is given from clinical assessment, routine blood tests or chest radiography then progression to further investigations for malignancy (US, CT, endoscopy, etc) would be inappropriate.
thanks saaid
ReplyDeletethe language used in some texts is provoked v. unprovoked thrombo-embolism
there is talk these days to using D-dimers at the end of a treatment course to risk stratify patients (with high riskers going on to longer courses of warfarin)
the BTS guidelines are old (2003) the european ones are more recent (2008)
there is an interesting NEJM case about diagnosing PE