صدق الله العظيم

1. بسم الله الرحمن الرحيم قالوا سبحانك لا علم لنا إلا ما علمتنا إنك أنت العليم الحكيم صدق الله العظيم

2. Lecturer of chest diseases Al-Azhar University CASE PRESENTATION Khaled Halima By

3. Personal history: ► Male patient. ►53 years old . ►Born, living in Eldarrasa . ►Married for 20 year. ►Electrical engineering . ►Heavy Smoker .

4. Stages 1/11/2009 …. 31/3/2010 III 1Month VI 2 Weeks I 2 Months II 1.5 Months

5. Stage 1

6. 1/11/2009----1/1/2010 ►Swelling of both lower limbs up to both knees. ►Bluish discoloration of skin . ►Pain in both heels.

7. Treated with : 1) Brufen 400mg 1x2 2) Augmentin 625mg 1x3

9. Referral to vascular physician

10. Received the following medications : 1) Colchicine tab 1x3 2) Marevan 5mg tab 1x1 3) Aspocid 75mg 2x1 4) Anti-cox cap 1x2 5) Thrombophob cream 1x2

11. New symptoms: -Increased bluish discoloration of skin up to the thighs. -Migrating pain and bluish discoloration of the skin appeared in both upper limbs.

12. What are the possibilities? 1- Cellulitis? 2- Vasculitis? 3- Local cause? Trauma V.V. I.V. Inject. 4- Burger’s Disease?

13. What investigations do you suggest? Normal 1-X-ray for both feet 2-Duplex for both LL. Superficial thrombophlibitis in GSV ( Great Saphenous Veins ) in both limbs more in left side with no evidence of DVT. 3-ESR. 125 Negative 4 . ANA, ANCA, AntiDS DNA

14. HB 13.4 PLT 507 TLC 14.7 5-Complete blood count. 6-Liver function test. 7-Renal function test.

18. I Superficial Thrombophlibitis 2 Months

19. Partial improvement

20. Stage II

21. 1/1/2010-------20/2/2010 Haemoptysis. Pleuritic chest pain in left side.

22. Referral to chest physician

23. What Investigations do you suggest? ■ Coagulation profile.

24. Coagulation profile

25. Complete blood count

26. Liver, Renal function test

27. ■ Chest X Ray P.A View 21/1/2010 4/2/2010

28. CT Pulmonary Angiography Pulmonary embolism involving the left lower lobar pulmonary artery & its anterior & lateral segmental branches with consequent left lower lobar pulmonary consolidation (likely an infarction & left sided mild pleural effusion).

29. CT Pulmonary Angiography 10/2/2010

30. - Pulmonary emboli at the posterior & medial segmental branches of the right lower lobar pulmonary artery.

32. Decision: Pulmonary Embolism.

33. I Superficial Thrombophlibitis 2 Months II Pulmonary Embolism 1.5 Months

34. Stage III

35. 20/2/2010----18/3/2010 Fever . Productive Cough. Dyspnea of gradual onset, progressive course, increased with mild exertion .

36. 20/2/2010

37. Developed: Marked Dyspnea. Fever Subsided.

38. 7/3/2010 8/3/2010 Before Aspiration After Aspiration

39. Simple aspiration was done >> Haemorrahgic in nature.

41. New Symptoms Marked loss of weight. Haemoptysis. Dyspnea at rest. Chest pain, severe back pain that decreased with potent analgesics.

42. Decision???

43. investigated by : 1- (INR: 9) So oral anti-coagulant was stopped. 2- X-ray: Massive left sided pleural effusion.

44. 15/3/2010

45. So thoracocentesis was done 4400 ml was aspirated by multiple sessions

46. What the cause of pleural effusion?? 1-Pulmonary embolism? 2-Pneumonia? 3-Marevan toxicity? 4-Trauma ? 5- Non of the above?

47. II Pulmonary Embolism 1.5 Months III Pleural Effusion 1Month I Superficial Thrombophlibitis 2 Months

48. Reevaluation

49. Stage IV

50. 18/3/2010……31/3/2010 progression of the previous symptoms