Case Report Pneumology

1. Case Report Pneumology Dr. David Tran A&E, FVHospital Medical meeting September 28th, 2011

2. Female 26 years old • Consults A&E on September 18th for chest pain, cough with small amount of blood in the sputum during the night. • Complains about shortness of breath for 2 or 3 days. • She mentions a traffic accident 3 weeks ago without thoracic trauma (just a small trauma at the R knee) • She has been in close contact with a acute case of tuberculosis a few months ago. • No past medical history, she smokes 20 cig./day.

3. Physical examination • Pulse 58/min, BP 100/60, RR 18/min., SpO2 100% (air), EVA 4/10, Glasgow 15. • Auscultation shows slight decreased mumure in the right base of the thorax, no rales, no crackles. • There is no sign of chest trauma, the ribs are not painful at palpation, the abdomen is soft. • The legs are not swollen, there is a splint on the right knee no pain at the right calf, no Homans sign.

4. ECG

5. Chest Xray

6. Hematological results

7. Biochemical results

8. D. Dimeres results

9. After discussion with the patient • She informed us that she had bed rest for almost 3 weeks after her accident due to the immobilization of the right leg in a splint. • She received no anticoagulation during this time. • She has no personnal or familial history of thrombosis. • She uses to smoke about 20 cig./day and takes oral contraceptive pils for 2 years.

10. Angio CT scanner thorax

11. AngioCT scanner of the thorax

12. Treatment • Perfalgan 1g + Morphin 3mg (scanner) • Lovenox 0.6ml (60mg) s/cut x 2 per day • Start Coumadine 4mg the day after • Check INR 48h to 72h after the onset of anti-vitK treatment. • Contention socks • Hospitalized in medical ward (Dr Thai, cardiologist)

13. DVT & Pulmonary Embolism • 117 cases / 100.000 persons in USA (increases with the age) • Importance of risk factors (immobilization, contraceptive drugs, flight travel, familial or personal past history) • Most clinical PE originate from a proximal DVT from the legs above the knee (popliteal, femoral or iliac vein) • As many patients have intermediate probability of venous thrombosis, clinical jugement is still the cornerstone of the diagnosis.

14. Risk factors

15. D-Dimer tests • D-Dimer are very sensitive but have a very low specificity (Good negative predictive value) • D-Dimer can rule out the diagnosis of PE in only 5% of patients aged > 80 years (60% in young patients < 40 years old) • Low risk of DVT assessment by validated prediction score and a negative D-dimer test (Latex agglutination) is deemed to rule out the diagnosis of DVT. • D-Dimer positive result does not raise the likelihood of DVT and has therefore limited clinical value alone.

16. Clinical probability score (Geneve Score)

17. Wells score of probability for PE

18. Assess clinical probability

19. Use of d-dimer and angio-CT for the diagnosis of Pulmonary Embolism

20. Decisional algorithm for the diagnosis of PE

21. CT pulmonary angiography(Se 83%, Sp 96%)

23. Principle of PE treatment • Immediate full anticoagulation is mandatory for all patients suspected of having have DVT or pulmonary embolism. • Diagnostic investigations should not delay empirical anticoagulant therapy. • Current guidelines recommend starting unfractionated heparin (UFH), low–molecular weight heparin (LMWH), or fondaparinux (all grade 1A) in addition to an oral anticoagulant (warfarin) at the time of diagnosis • Discontinue UFH, LMWH only after the international normalized ratio (INR) is 2.0 for at least 24 hours, but no sooner than 5 days after warfarin therapy has been started (grade 1C recommendation).

24. Curative Treatment • Low molecular weight heparin (LMWH) • LOVENOX 0.1ml/10Kg sub-cut twice a day • Early relay with anti-vitamin K by mouth • INR after 48-72h of treatment • Stop Heparin when INR 2< <4 at 2 times • Duration of efficient anticoagulation minimum 3 to 6 months (according persistent risk factors)

25. Think to Pulmonary Embolism!