34: Short of Breath

A gentleman presents with shortness of breath and leg edema for 2 months that has become worse during the last 2 days.  He has a history of diarrhea & protein wasting due to prior gastric bypass surgery, but is otherwise healthy.  He denies fever, chest pain and cough.

On exam vitals are notable for tachypnea and tachycardia.  Pulse ox is 95% on room air.  The oropharynx is moist and his lungs are clear without wheezing or rales.  His legs have 1-2+ bilateral edema with a negative Homan’s sign and no erythema.
EKG: atrial fibrillation at a rate of 158 and nonspecific ST abnormalities.

CBC: white count of 11, platelet count 137,000.

Chemistry: sodium 150, chloride 128, carbon dioxide 11, anion gap 11, creatinine 1.7, magnesium  low at 1.2,  albumin 1.7.

Troponin undetectable.  BNP normal.

ABG on 2L O2: pH 7.36, pCO2 15, pO2 102.

Below is his chest x-ray.  What diagnostic findings are shown?  What is the treatment?

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HINT: Hypoprotenemia may be a risk factor for this condition

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Answer: Hampton’s Hump from Pulmonary Embolism

VQ scan of same patient showing perfusion defect in left lingula

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EXCERPT ON DVT/PE Risk Factors

from

QUICK ESSENTIALS EMERGENCY MEDICINE

BLOOD CLOT RISK FACTORS:
BASICS:    Lack of risk factors should not prevent the workup when there is no alternated diagnosis
20% of patients diagnosed with PE/DVT had no identifiable risk… until they had a workup
Workup often reveal cancer in older patients and hypercoagulable state in younger pts.
Virchows:     Immobility, Injury, Hypercoagulable State
Major Risks:     Surgery <3mo, major trauma, recent admit, active CA(esp. breast,ovary,brain), central line
Heme:    Usually presents age <35: Protein C&S deficiency; Antithrombin 3(heparin fails);
Newer:    Factor V Leiden > G20210A Prothrombin mutation, dysfibrinogenemia, homocystinuria
Diseases:    DIC, paroxysmal nocturnal hemoglobinuria,
Homocysteinuria, HIT, Polycythemia, essential thrombocytosis
APLS:    AntiPhosphoLipid syndrome includes anticardiolipin Ab and Lupus anticoagulant
Vein: DVT, PE; Artery: CVA, late fetal loss; livedo reticularis; alone or ĉ SLE
Lab:    Low platelets, prolonged PTT, hemolysis
Rx:     Coumadin for INR > 3 (up to 4.5) for life iff DVT
Other Risks:    Trip >6h, pregnant <3mo ago, cast, IVDU, Crohns,
Nephrotic syndrome (loss of protein C&S), OCP, tamoxifen
Possible:     CHF, ESRD, smoking, obesity, COPD, thalidomide
Arm Risks:     Central Line(20% get one), pacer, AICD, golf, throwing sports, weights, tennis

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