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This patient is a
55-year-old white woman with right knee surgery six weeks prior to
presentation. She had five days of Lovenox postop. She
presented with acute onset of dyspnea on exertion resolved with
rest and progressed to dyspnea at rest. She reports some chest
tightness and shortness of breath without any cough, fever,
chills. No calf tightness or lower extremity edema. No
complications after
her surgery. VQ scan was obtained after ABG revealed 7.44, 27, 61,
18 on room air and the patient's dedimer returned at 3. VQ scan
was read as high probability for a pulmonary embolus and she was
started on 100 mg subcu Lovenox in the ER with no further episodes
of dyspnea, chest pain. She has a past medical history of migraine
headaches and degenerative joint disease. She has a past surgical
history of right knee arthroplasty 7/03 and c-section x3. She is
allergic to sulfa meds. Medications at home include Calan 240 mg
q. day, and Midrin and Toradol p.r.n. for headache as well as
NSAIDs and hormone replacement for hot flashes. She reports no
tobacco, alcohol or IV drugs. Lives with her husband.
PHYSICAL EXAMINATION:
Temperature 98, blood pressure 146/97, heart rate 98, saturation
94% on room air.
CHEST: Clear bilaterally without wheezes or crackles with some
vesicular breath sounds in the right base.
LABORATORY DATA:
White count 12.5, H and H 13.7 and 42.8, platelets 298, INR 1.1,
electrolytes within normal limits, creatinine 1.1, cardiac enzymes
within normal limits. EKG showed sinus tachycardia without ST-T
wave
changes and chest x-ray showed no focal infiltrates or effusion.
She was admitted to team 3A internal medicine with Lovenox subcu
b.i.d. and started on Coumadin 5 mg q. day. Lower extremity
Dopplers were obtained, which revealed a right popliteal DVT
around the area of residual Baker's cyst. The patient did well in
the hospital without any further episodes of shortness of breath,
continued on the Lovenox
with Coumadin and is to be discharged home on Lovenox 100 mg subcu
b.i.d. to take until her Coumadin is therapeutic. She is to take 5
mg of Coumadin once a day, to follow up in the Coumadin clinic
next week, also to follow up with Dr. on Monday for postop care
and for an INR check and Coumadin adjustment. She is to follow up
with her primary care doctor, in two to four weeks, and is to stop
taking hormones that she was on before and to back off on taking
NSAIDs as much as possible. The patient understands these
instructions and agrees to keep all appointments and take
medicines as
prescribed.
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| Radiology
Report: |
| Technique:
Perfusion phase of the exam is performed with 11.7 mCi of
99mTc MAA IV. The initial dose of 99mTc DTPA aerosol for
ventilation was 57.2 mCi. The study is compared to a
plain chest film obtained the same day.
Findings: The chest
X-ray is within normal limits without evidence of focal
infiltrates or atelectasis. The ventilation images
demonstrate no evidence of defects. The perfusion images
demonstrate defects in the apical and posterior segments of
the right upper lobe. These findings are consistent with
high probability of pulmonary embolus.
IMPRESSION: HIGH
PROBABILITY FOR PULMONARY EMBOLUS |
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Images courtesy of UAMS Dept of
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