CQCC 3

Amarpreet
Teh Nin Min
Lossini
Bavi

Trigger 1

Mr X
Malay
66 year old gentleman
Retired school teacher

Presented to HKL A&E department with complaint of shortness of

breath for a day associated with chest pain and cough

Differential diagnosis???

What further history to elicit?

Trigger 2

SOB: 1day,sudden in onset occur when patient was walking to bathroom, lasted for 10
minutes, unable to speak in complete sentences(short phrases), aggravated by exertion, no
relieving factor

Chest pain: acute in onset, intermittent, sharp stabbing pain at central region, radiating to
back, aggravated by cough and on exertion and no relieving factor
The patient experienced palpation and dizziness after few minutes of SOB. He sat on a chair
and his son brought him to hospital. On the way to hospital, he had productive cough.
Colourless sputum with no blood tinged.

No orthopnea, no PND, no fever

No ill contact

# prior to SOB Mr X had a history of left leg pain for 2 days (sudden onset, intermittent pain,
dull, relieved by rest, aggravated by movement, pain score 4/10)

 PMH:
Underlying hypertension for past 10 years diagnosed during routine
medical check , currently in a 4 monthly follow up at KK Taman AU2.
He is on antihypertensive medication (Captopril) and compliant with
treatment
PSH:
1st admission-OA at left knee diagnosed in HKL a year ago and
underwent total knee replacement 10 days ago. He was discharged
after day 4 of operation.
Allergic history:
No known allergy to food or medication

 Family history:
Father passed away at age 53 due to MVA, mother is 90 years old and
has hypertension and dyslipidemia, currently on follow up treatment
at KK AU2 and is compliant to her medications. No other relevant
family history.
Social history:
Smokes 40 packs per year, not consume alcohol, not taking any illicit
drug

Trigger 3
What physical examination will you like to perform?

Vital
signs
HR: 120bpm
BP: 120/76mmHg
Respiratory rate: 26bpm
oxygen saturation: 89% under room air
Temperature:37.6C

BMI: 31
Weight : 88 KG
Height : 169 cm

Summary of findings
General examination: Normal (No pallor, cyanosis, cervical
lymphadenopathy, peripheral oedema)
Systemic examination:
Respiratory examination: chest expansion is restricted. Tracheal
deviation, tactile fremitus and percussion are normal. Air entry are
equal with normal vesicular breathing. Pleural rub is present.
Cardiovascular examination: Apex beat at 5th ICS at midclavicular line.
5S1 and S2 are heard, with no murmur

Trigger 4
which diagnosis to be rule out?
what investigations to do?

Investigations

CBC: Hb:15.9 dL; WCC: 7x10^9/L; platelet: 270x10^9/L

LFT:normal
Coagulation profile
BUSE : normal

D-dimer is used in patients without high probability of Pulmonary

Embolism.
o Negative test effectively excludes it; no imaging needed
o Positive test does not prove the diagnosis; imaging is needed

ABG
pH: 7.42
pCO2:33.2(reduced)
pO2:55(reduced)

chest X-ray

CT pulmonary angiography

Ecg sinus tachycardia

Risk Factors

Previous or current DVT

Immobilization
Surgery within the last 3 months
Stroke/paralysis
Central venous instrumentation within the last 3 months
Malignancy
CHF
Autoimmune diseases
Air travel *
Thrombophillias
In Women
o Obesity (BMI 29)
o Pregnancy
o Heavy cigarette smoking (>25 cigarettes per day)
o Hypertension

Wells Score
Clinical symptoms of DVT (leg
swelling, pain with palpation)

3.0

Other diagnosis less likely

than pulmonary embolism

3.0

Heart rate >100

Traditional clinical probability

assessment (Wells criteria)
High

>6.0

1.5

Moderate

2.0 to 6.0

Immobilization (3 days) or
surgery in the previous four
weeks

1.5

Low

<2.0

Previous DVT/PE

1.5

Haemoptysis

1.0

PE likely

>4.0

Malignancy

1.0

PE unlikely

4.0

Simplified clinical probability

assessment (Modified Wells criteria)

Simplified Geneva Score

Variable

Score

Age >65

Previous DVT or PE

Surgery or fracture within 1 month

Active malignancy

Unilateral lower limb pain

Hemoptysis

Pain on deep vein palpation of lower limb

and unilateral edema

Heart rate 75 to 94 bpm

Heart rate greater than 94 bpm

+1

Score of less than 2 is low probablility for PE, score of less than 2 plus a negative D-dimer
results in a likelihood of PE of 3%

Presentation
Most Common
Symptoms

Pleuritic pain
Cough
Orthopnea
Calf or thigh pain
Calf or thigh swelling
Wheezing
Rapid onset of dyspnea
Dyspnea at rest or with
exertion

Most Common Signs

Tachypnea
Tachycardia
Rales
Decreased breath sounds
Accentuated pulmonic
component of the second heart
sound
Jugular venous distension

management
thrombolysis
tissue plasminogen activator
TPA
o Alteplase IV drip 100mg over 2 hours

Streptokinase
IV drip 250,000 units over 30mins
Followed by 100,000u/hr for 24hrs
Urokinase

 Contraindications
Absolute Contraindications
Intracranial neoplasm
Recent (<3 months) intracranial surgery or trauma
recent (<3 months) ischemic stroke
h/o hemorrhagic stroke
Active or recent bleeding
Relative Contraindications
BP > 180 systolic
H/o ischemic stroke
Recent (<4 weeks) internal bleeding
Thrombocytopenia

 anticoagulant
1. low molecular weight heparin
Administered subcutaneously
Examples include
Enoxaparin BID or once daily dosing
Dalteparin once daily
Nadroparin BID dosing (not for use if wt >100kg)
Tinzaparin
Do not require monitoring in most cases

2. Warfarin
Started after administration of heparin (or heparin like agent)
Adjusted dose to INR 2.0-3.0

Surgical embolectomy
requires cardiopulmonary
bypass
indicated as an alternative to
thrombolysis or when
thrombolysis is contraindicated

Inferior vena cava filter

"filter out" large emboli from
the pelvis , lower extremities
inserted percutaneously
indicated for patients who have
contraindications to
anticoagulation

THANK YOU