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Real Doctors (Life Makers)  |  Clinical  |  Medicine & medical subspecialities  |  Common Cases « previous next »
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cleo_md
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Common Cases
« on: /September/ 30, 2005, 07:01:11 AM »

ACUTE SHORTNESS OF BREATH IN A YOUNG WOMAN.

CC: " I can not breathe"

HPI A 39 year old female generally in good health presents to an urgent care facitility complaining of severe shortness of breath and sharp pain in her chest when she takes a deep breath. She is anxious due to the pain and she feels light headed. She has no other complains- no fevers , chills, cough, trauma, leg pain or swelling , abdominal pain , nausea or vomiting, diarrhea/constipation or urinary symptoms.

PMHx:None

Meds:
Oral contraceptive pills

All:None

SHx:
Works in a computer technology firm, not sexually active, HIV test 3 months ago -ve, smokes one ppd for 16 years
social alcohol , no IV drug abuse
occasionally uses marijuana.

VS:
T 37.5   HR 135  RR 28  O2 sat 88% on Room air

PE:
Generally anxious, thin, dyspneic young woman in apparent respiratory distress, using accessory muscles of respiration.
HEENT- Clear
Neck- JVD elevated , No lymphadenopathy
Heart- RRR S1 heard , loud S2 , tachycardic RV lift present
Lungs-a few wheezes but otherwise clear
Abdomen-soft ,BS+ , not tender and not distended
Ext- No edema or tenderness

Labs:
WBCs 10,000
Hct 38
Plts 210,000
Lytes and liver panel - within normal limits
Urine hCG -ve
ABG-  7.48/30/68 on Room air
ECG: sinus tachycardia, right axis deviation
chest X ray - normal



 As we can see here the patient's shortness of breath is very concerning .
Red flags ( warning signs for us ) in her case are
- HR 135 ( tachycardia)
-Oxygen sat of 88 on room air
-The "sudden" onset of the shortness of breath

« Last Edit: /September/ 30, 2005, 07:28:43 AM by cleo_md » Logged


 
cleo_md
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Re
« Reply #1 on: /September/ 30, 2005, 07:40:12 AM »

Thought questions:

-
1- What is the patient's calculated A-a gradient?
2-What is the most likely diagnosis of this patient's shortness of breath?
3-What are some of the chest x ray findings associated with this diagnosis?
4-What is virchow's triad?


The A-a gradient or the alveolar-arterial gradient can be calculated from the following equation

714x FiO2-1.25(PCo2)-Po2

FiO2 in this case is 0.21 as the patient is on room air

=150-1.25(30)-68
=44.5

This patient most likely has suffered an acute pulmonary embolus, given her sudden onset of shortness of breath without any underlying pulmonary disease accompanied by profound tachycardia , dyspnea and hypoxemia. Physical findings also commensurate with the diagnosis including the finding of right heart strain . The ABG confirms respiratory alkalosis and hypoxemia with an elevated A-a gradient.
Also her ECG shows right axis deviation

The chest Xray in her case was normal . Although findings with pulmonary embolism may include pleural effusion,atalectasis ,pulmonay infiltrates" Hampton humps" or "westermark sign" the Xrays in pulmonary embolism are usually unremarkable.

Virchow's triad
defines the 3 main risk factors for intravascular thrombosis
1) abnormalities in the vessel wall
2)abnormalities within the circulating blood
3)stasis of the blood flow or loss of the laminar flow

In this case the patient is on oral contraceptive pills which made her hypercoagulable and in turn made her more prone to pulmonary embolism.
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