Concluded Case

62 year female was admit in govt hospital 8 days back with diagnosis of dvt rt leg and thrombus in ivc. Pt came to with c/o dyspnea, cough from three days and blood in sputum from one day. On examination bp was 140/90, b/l crepts, clubbing was present. Pt was o2 dependent and spo2 was 70 %, with o2 it was 94%. Investigations are as below Expert opinions are welcomed Update 1 : 2DECHO -severe pulmonary artery hypertension -Dialeted RA RV -thrombus in IVC -LVEF 55%



Concluded answer

It was a case of extensive venous thrombosis with pulmonary thromboembolism and secondary infection lung.

All Answers

Pulmonary thromboembolism with DVR I left leg treatment I agree

I agree

CTPA would definitely help in this case, not only to look at emboli in the pulmonary vasculature but also to look at the underlying lung parenchyma. We have to exclude other causes of group 3 pulmonary hypertension too. If CTPA definitely shows multiple clots, prolonged anticoagulation will help. Riociguat has been recommended in CTEPH as per new evidence. Oxygenation using high flow nasal oxygen would be better as compared to BiPAP. So my plan here would be, CTPA to be done. If clots+ prolonged anticoagulation with diuretics + riociguat If no clots- treatment of underlying lung disease, Oxygenation through high flow nasal oxygen.

Valuable opinion

Ecg shows S1Q3T3 suggestice of pulmonary CT angio to rule out pulmonary embolism 2D echo is less invasive where one can caluculate right venticular pressure Heparin therapy is reccomended For IVC thrombus IVC filter placement is required

Doppler test for Dvt.

Needs throughly investigation - x-ray chest, echocardiogram, CT scan chest,Rft,Lft sputum for AFB & c/s, B.sugar any old h/o past illness etc.

RAD, LPHB, RVH with strain. S1,q3,t3. T inversion in nearly all leads. Pulmonary embolism. CXR.... Pulmonary oedema. Adv. Pulmonary angio. Echo. BIPAP, anticoagulants, diuretics, nebulization

CXR- diffuse infiltration on rt lung Cardiomegaly LT LZ haziness may suggest basal congetion ECG- S1Q3T3 with RV strain ABG- alkalosis, metabolic CBC- increased WBC Doppler RLL- thrombosis in femoral , IVC Chronic lung disease with PAE Adv D dimer assay - highly specific for neg prediction Echo- RA-RV dilatation, TR Spiral chest CT with IV contrast: Accurate for identifying PE in proximal pulmonary tree Rx O2 Thrombolysis / LMWH Bronchodilators Antibiotics

Please do CA19_9 a serum biomarker & CEA

Pt has got extensive venous thrombosis, please do venous & arterial Doppler on both sides. Such a presentation is usually due to underlying malignancy which in this case could be pancreas. ECG is suggestive of probably trans anterior infarction & x-ray picture is suggestive of pul embolism with 2dary infection. Also get homocysteine levels done.

Thank you doctor

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Metabolic alkalosis, Hyperglycemia, ECG S1 T3Q3, T version in lat leads. low voltage complex. Leucocytosis. Cxray cardiomegaly Rt hezy hemithorax. Inf Pulmonary arterial enlargement. Possibly PAE with chronic Lung disease with secondary infection. Sugg, 2D echo, PTCA, antibiotics, bronchodilators mucolytics, Treatment as anticoagulation and thrombolysis once PAE confirmed.

Pt is on fondaflo and warf with insulin
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