Thread by @DIskandarmirza

For Junior Doctors

Let us have a brainstorming session shall we?
Real patient with real management from me 😉

Scenario

40 years old
- obese
- came with back carbuncle
- operated with no complication

This is his cxr prior to admission

Day 4 of admission

- Having shortness of breath
- suddenly desaturated, needing oxygen support
- Hypotensive needing inotropic support
- no fever, cough

- lungs: clear
- S1S2 no murmur

Blood investigation
- no leucocytosis

This is his repeated chest xray on day 4 of admission

What you guys can see from this chest xray?

Yes , oligemic lung field. If you guys cant see the changes, please refer to previous cxr.

it is also called Westermark sign

Westermark sign is a chest x-ray finding of oligaemia (clarified area) distal to a large vessel that is occluded by a pulmonary embolus.

The focal area of increased translucency due to oligaemia is caused by impaired vascularisation of the lung due to primary mechanical obstruction or reflex vasoconstriction

So how do we confirm our diagnosis?

Yes CTPA was done and it showed massive pulmonary embolism. Patient is diagnosed to have a provoke pulmonary embolism.

Pulmonary embolism (PE) is a life-threatening condition resulting from dislodged thrombi occluding the pulmonary vasculature; right heart failure and cardiac arrest may ensue if not aggressively treated.

Clinical probability, assessed by a validated prediction rule and clinical judgement, is the basis for all diagnostic strategies for PE. Computed tomographic pulmonary angiography is the definitive diagnostic investigation.

Management?

First you need to classify whether the patient is hemodynamically stable or unstable

hemodynamically unstable
- Thrombolysis or thrombectomy

hemodynamically stable
- Anticoagulant

Easy right?
That is all from me tonight