41: Exertional Dyspnea

A 56 year old man presents with 2 months of worsening dyspnea on exertion.  Now he can’t even go up the stairs without getting severely short of breath.   There is no fever, cough, chest pain, leg swelling or other symptoms.  He has no past medical history and his only medication is a steroid cream for a skin condition.

On exam he is afebrile with a pulse of 108, a BP of 118/70, respirations at 20, and a pulse ox of 94% at rest.  His lungs are clear without rales or wheezing, his heart is regular without murmur and his legs have no swelling, tenderness or cords.  The rest of his physical exam is normal.

His CXR & EKG are shown below.  What condition or conditions should you worry about and in what order.  Is his presentation “typical” or “atypical”?

 SCROLL DOWN FOR CASE ANSWER AND TO MAKE COMMENTS

************************************************************

<<<<<<<<<<<<<<<<<<<< SPACER >>>>>>>>>>>>>>>>>>>>

Get Cornucopia: Emergency Medicine or Quick Essentials: Emergency Medicine

<<<<<<<<<<<<<<<<<<<< END SPACER >>>>>>>>>>>>>>>>>>>

***********************************************************

Answer: Massive Pulmonary Embolism

Chest X-ray is normal, but EKG shows T-wave inversion in V1, V2 & V3 which is a frequently missed but classic finding in large PE’s (which also are frequently painless: more below) that often leads the physician astray looking for acute coronary syndrome.  CT-chest is shown below.

*

EXCERPT ON PULMONARY EMBOLISM

from

QUICK ESSENTIALS: EMERGENCY MEDICINE

 

PE: PULMONARY EMBOLISM: PITFALLS:
Clinical:    Small PE’s missed because pain only, but usually no tachycardia or hypoxia
Large PE’s missed because often painless with only SOB, DOE or syncope
Risk factors abscent in 20% (usually clotting abnormality in young and cancer in old)
Tests:        Large PE’s missed because can cause EKG & troponin changes that look like ACS/MI
D-dimer can be false negative if on heparin or coumadin or symptoms > 1week
CT-chest is only 83% sensitive and has more radiation than VQ. Trop & BNPï‚­ if RV strain

PE: PULMONARY EMBOLISM: CLINICAL PRESENTATION
Sources:     20% neck & arms DVT, 20% calf DVT, 60% proximal leg DVT, renal/hemorrhoidal vein
Symptoms:    SOB/DOE:84, Flank/chest pain:88 (pleuritic:74), sweating, syncope:13 (#1 miss)
PIOPED-2:    SOB/DOE:79, Pleuritic pain:47 (other studies:88%), non-pleuritic:17, cough:43, leg sx:42-50
Large PE:    SOB +/- pain (SOB may be exertional only) > hypoxia, painless syncope, hypotension.
Small PE:    Pleuritic pain, (SOB), normal VS and pulse ox, cough:53, hemoptysis:30
Signs:     RR >16:92, rales:58, P2 > S2:53, HR:25-44, temp, murmur, wheeze, rub, JVD, Tender: 13
PIOPED-2:    RR>19:57, HR>100:26, T>101.3:2, JVD:13,  P2:15, rales:21, sounds:21, DVT signs:47
Well’s Criteria: 3points: suspect DVT, no good alternate dx.
1.5points: HR>100, OR/immobilization<4wks, h/o PE/DVT.  1point: CA, hemoptysis
Total points:    <2: low risk (3.5%).  2-6: medium risk (20%).  >6: high risk (67%)
PERC Tool:    PE Risk Criteria: Only to be used in patients where you feel they are low risk for PE.
If low IOS and PERC negative, risk for PE is < 2% and no testing OK according to author
Criteria:    Age<50, Pulse <100, SaO2>94%, No unilateral leg swelling, No hemoptysis,
No recent trauma/surgery, No prior PE/DVT, No hormone use

PE: PULMONARY EMBOLISM: TESTING
PE EKG:           (Transient): tachy:26-44%, Twave inversion:42%, ST/:26/16, P pulmonale (lead II):2-31%
Nl: 12, S1Q3T3: 12, fake MI: 10, incomplete RBBB: 10, AVB, L-axis > R-axis
PE CXR:    Elevated Hemidiaphragm >Atelectasis > Cardiomegally >Effusion >Infiltrate >
Enlarged pulmonary artery >Oligemia >vascular cutoff (Westermark sign)
D-dimer:    85%, age >60 too many false positives.  False negative if on heparin/coumadin or sx > 1wk
Pretest IOS:    Presentation: classic, typical, atypical,  Alternative Dx?  Major RF present
V/Q:           Pros: 98% sensitive, radiation = 2mSv, no contrast, wait. If nl CXR only 10% non-diagnostic
Cons: >1h scan time, doesn’t pick up alternate dx, less specific
PIOPED-1:    VQ results & % ĉ PE: nl:2; low:16; intermed:41; high:41.  r/o PE ĉ low IOS & low prob. scan
CT Angio:    Always ask radiologist how good scan quality/dye timing was and how confident they are.
Pros: makes alternate dx, more specific than VQ, rapid: unstable pt, COPD/abnl CXR
Cons: 83% sensitive (worse if obese or 1-4 slice), radiation >8mSv, IV contrast via AC IV
PIOPED-2:     CT Angio: 83/96 (only 83% sensitive for PE).  “If high clinical prob, need 2nd  test to rule out”
Worse Prognosis: cardiac septum deviated to R, contrast reflux into hepatic veins
Duplex too?    + in only 29% aSx legs but the next one kills.  36% of arm DVTs >PE.  Combo testing wise.

726

Comments