33 yrs old male pt admitted with the complaints of breathlessness for past 4 days and aggravated since today morning. . pt conscious. dehydration present tachypnea present PR. 106 per mnt BP. 100 / 70 mmhg RS. . NVBS + NO ADDED SOUNDS CVS. S 1 S 2 HEARD. NO MURMUR ECG TAKEN. . 1. CLINICAL DIAGNOSIS? 2. ECG FINDINGS? 3. HOW TO APPROACH THIS PT? plz share your views. ...

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BREATHLESSNESS DEHYDRATION HYPERGLYCEMIA clinically diagnosed as a case of NEWLY DETECTED DIABETES WITH DKA ..METABOLIC ALKALOSIS COMPENSATED BY RESPIRATORY ALKALOSIS. . URINE ACETONE. .POSITIVE ECG SHOWS .. SINUS TACHYCARDIA RAD RBBB LPFB SIMULATANEOUS T WAVE INVERSION IN INFERIOR AND ANTEROLATERAL LEADS. . ALL ARE INDICATIVE OF ACUTE CORPULMONALE. .DUE TO PULMONARY EMBOLISM. . clinical diagnosis is DKA WITH SUSPECTED PULMONARY EMBOLISM. . TREATMENT GIVEN. . OXYGEN. .IVF. .NS. . INSULIN DRIP INJ.HEPARIN 5000 U IV FOLLOWED BY 1000 UNITS PER HOUR. .GIVEN THEN PT REFERRED TO HIGHER CENTRE FOR ECHO. .CT ANGIO. . ILL UPDATE ONCE I GOT THE REPORTS ... SHALL WE THROMBOLYSE THE PT ONLY WITH CLINICAL DIAGNOSIS?

In cases of Acute PTE, only in high risk patients with Haemodynamic Instability, We can Thrombolyse the patient's. In these patients, we should ask for D dimer levels with sample taken before Thrombolysis . It's not feasible to take for CT pulmonary angio, if the pt is haemodynamically Unstable, so decision to be taken moreover on clinical grounds. If the pt haemodynamic stable, then we can wait for ct pulmonary angio
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Ecg is showing sinus tachycardia s wave in lead 1 q waves and T wave inversion in lead 3 rsr in V1 T waves inversion in precordial chest leads All finding suggestive of Acute PTE urgent CT pulmonary angiography, because of high clinical suspicion If diagnosis confirmed decision to thrombolysis, will be taken if high risk factor present because patient is hemodynamically stable high risk factor include RV overload, RV hypokinesia on echo proximal location of thrombus on ct angio some have considered cardiac troponin positive also as high risk if no high risk then anticoagulation with bringing heparin therapy

Thank you so much sir
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SINUS TACHYCARDIA ,,WITH BREATHLESSNESS IS THERE ANY H/O CHEST PAIN OR ANGINA, ,FEVER, ,WATS THE SPO2??CHEST IS CLEAR, ,IS PT. ASTHMATIC, ,COMPLETE HISTORY, ,PUT HIM ON O2 BY NASAL PRONGS AT 2 LITRE /MIN, ,TPR /BP /IO /SPO2 CHARTING, ,DO FBP, ,FPBS, ,S CREAT, ,SGPT, ,S ELECTROLYTE, ,CUE, ,CXR, ,,TFT, ,PROPPED UP POSTN, ,IV PAN 40, ,IV EMNIL, ,TB RESTYL 0.25 STAT, ,IVF, ,R/O CAUSE ACCORDING TO REPORTS THEN PROCEED FURTHER

Thank you sir
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agreed Acute PTE but there is also some degree of ischemia of inferior and lateral walls since this patient had Diagnosis of DM he could be also in DKA and or Renal failure Also since the diagnosis of PTE and DM check out with Abd USG for portal and IVC thrombosis and pancreatic tumors DVT is a known predecessor to malignancy and apart from RV infarction

Malignancy should be considered along with other problems history of recent long distance travel to be asked if negative then others including Reiter's and Bechet syndrome can cause DVT and PTE usual tests for Thrombophilia,protein C,S, antithrombin 3,factor 5,Prothrombin variants, hyper viscosity syndromes are rare in such a young age
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sinus tachycardia with s1q3t3 pattern... high suspicion of pulmonary embolism ... get HRCT as soon as possible with d dimer .. are there any risk factors for embolism ?? 2d echo also must

use iv fluid judiciously and if possible cvp for iv fluid monitoring... if HRCT not available this time then send d dimer and coagulation profile and start with heparin 25000 units over 24 hours... 85 % of PE are mild risk only... but as u said breathlessness is persistent better to use heparin
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Thank you so much for Dr. shailesh sir. Dr. Kiran sir. .and Dr. shafiq sir. ..For fantastic approach. .. ECHO NOT DONE. .NON AVAILABLE AT THAT TIME. . RBS ..296 MGS. .

thanks sir do update us with ct angio film pic and if possible still image of echo would realy appreciate it
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S.tachycrdia S1Q3T3 RAD LPHB T wave inversion in inf leads & v1 to t non progression of r wave across the chest leads P.E is most probable Dx

V1 to v6
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This is a case of anterior wall myocardial infarction.

Pulmonary embolism. Do d dimer anticoagulant. Two D ECHo is to be done.

Thank you sir
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Anterior wall infarction with old inferior wall infarction, advised ICU management.

Thank you sir
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