肺栓塞教学查房 .pptx

Teachingwardround -Pulmonary embolismGeneralcondition The patient is female.She is 41 years old.ChiefcomplaintPresented with persistent left chest pain for 8 days.PresentHistory Eight days ago,the patients presented with persistent left chest pain,but no incident cause or other complaints.The chest pain was more severe when the patient took a deep breath.So she went to another hospital.A CT scan showed scattered small ground-glass opacities in the bilateral lung field and a well defined dense shadow in the left lung.Chest ultrasound confirmed left pleural effusion.The patient was diagnosed with double pneumonia and left pleural effusion.The patient received antibiotics for 8 days,which slightly alleviated the left chest pain.The patient was transferred to our hospital for further diagnosis and treatment.Chest CT scan 3 days before admission PasthistoryThepatienthadnohistoryofrecentsurgeryordeepvenousthrombosis.shehadnevertakenoralcontraceptives,andshedenieddrinkingalcoholandsmokingcigarettes.Physicalexamination T 36.5,P 71bpm,R15bpm,BP118/85mmHg,SaO2:98%.Normal development,medium nutrition,conscious,Superficial lymph nodes enlargement was not found.Auscultation double lung breathes sounds clear.Noabnormalitiesinheartandabdomenexaminations.ExaminationWhite blood cell count,liver function,kidney function,myocardial markers,and brain natriuretic peptide values were normalD-dimer level was 0.02mg/L.A repeat chest CT scan on the first day after admission showed scattered small ground-glass opacities in the bilateral lung field,but no pleural effusion in the left lung ECG revealed sinus rhythm and ST-T wave changes,and myocardial ischemia was suspected Echocardiography showed that ejection fraction was 77%,the right ventricle end-diastolic diameter was 23mm,tricuspid valve regurgitation Abdominal ultrasound showed no abnormalities of the liver,gallbladder,pancreas,spleen,or kidney.Chest CT scan 1 day after admission DiagnosisandTreatmentDouble pneumonia was suspected,and the patient was prescribed another course of antibiotics.Two days later,the patients left chest pain was alleviated;however,a similar but more severe pain appeared in the right chest.Further clinical assessments showed the patients D-dimer level was 0.08mg/L,and chest CT scan revealed right pleural effusion had emerged.For further diagnosis and treatment,a CTPA was performed.Findings were consistent with a PE in the right pulmonary artery,and a small amount of pleural effusion was seen on the right.CTPA 5 days after admission CTPA 5 days after admissionTreatment The patient was treated according to the guidelines for the diagnosis and treatment of PE.Low-molecular-weight heparin calcium injection 4100 IU was administered twice daily by subcutaneous injection.Chest pain was fully alleviated after 6 days,and oral anticoagulant rivaroxaban was given after discharge.Three months later,a lung perfusion scan showed the PE in the right pulmonary artery had significantly improved,and ultrasound showed no evidence of pleural effusion.Discussion Clinical manifestations of PE are complex and diverse,and the rates of clinical misdiagnosis and missed diagnosis are high.Globally,PE is associated with mortality,with 30%of PE patients dying during the initial 30 days after diagnosis.As correct management of PE can reduce the mortality rate to 10%,timely and accurate diagnosis and treatment of PE are essential.In the current study,the patient initially presented with left chest pain;she was diagnosed with double lung pneumonia and left pleural effusion.Pleural effusion may be caused by heart failure,pneumonia,cancer,and tuberculosis.In the current study,based on the patients clinical manifestations,the chest pain was initially thought to result from parapneumonic effusion.However,administration of anti-inflammatory treatment only slightly reduced the left chest pain.New pain appeared in the right chest,which did not support a diagnosis of parapneumonic effusion;therefore,we considered occult PE.In the current study,the patients D-dimer level was not remarkable.Generally,there is a dose-response relation between D-dimer level and risk for a PE.However,a PE diagnosis should not be made based on D-dimer levels alone as the test lacks specificity.If D-dimer levels are within the normal range,a diagnosis of PE can almost be excluded if the patients clinical probability score for a PE is low.In patients with high D-dimer levels and a high clinical probability of PE,further tests should be used to make a definitive diagnosis.In clinical practice,PE can be easily missed or misdiagnosed based on a normal D-dimer level.We recommend the use of CTPA to investigate the possible presence of occult PE in patients with unexplained pleural effusion and normal D-dimer levels.Thank you