1. Image of the week Jagdish K Prof. Dr. A Gowrishankar’s unit m3

2. 65 yr old male, who is a known smoker for the past 40yrs, presented with acute worsening of pre existing long standing breathlessness, 10 days prior to presentation No h/o fever, cough or expectoration h/O fracture neck of femur after trivial fall in bathroom 3years back and he was not ambulant since then.

3. O/E Pulse 110/min BP 130/80 mm of hg Conscious, oriented, afebrile Conjunctiva suffused CVS – S1 normal, P2 loud RS :B/L Wheeze+, Right base BS↓ Other systems normal

4. Chest X ray

5. ECG

6. exudative 60 lymphocytes/cumm 6 mesothelial cells/cumm Ada – 16 iu/l Pleural fluid analysis

7. 700ng/ml D dimer

8. CT Chest

9. “ Few health care providers realise the case fatality rates for pulmonary embolism is 15%, exceeds that of acute MI” Pulmonary embolism

10. Risk factors

11. Inherited Acquired Thrombophilias

12. Endotelial injury Stasis Hypercoagulablility Virchow’s Triad

14. Most common symptoms & signs

15. Well’s clinical decision rule

16. Mild Moderate Severe Paradoxical Pulmonary infarction syndrome Nonthrombotic pulmonary embolism Diverse clinical scenarios

18. Pulmonary infarction syndrome

19. Oxygen saturation Chest x ray D dimer Investigations

20. ECG changes

21. Echocardiographic changes

22. Multidetector CT – The one stop shop CT Angiography

23. CT PULMONARY ANGIOGRAM

25. Lung scanning Pulmonary angiography Venous ultrasound MRI continued

26. Clinical predictors of increased mortality

27. Biomarkers & imaging predictors of increased mortality

28. Approach to the patient

30. Lack of written diagnostic algorithm Failure to use clinical probability scoring Ruling out pulmonary embolism based on normal venous ultrasound of legs Not evaluating after finding an abnormally elevated D- dimer test Delay in seeking medical attention 5 common errors

31. “Can also occur concomitantly with other illnesses , thereby confounding the diagnostic work up”

32. “ The greatest challenges are to remember to consider the possible diagnosis of pulmonary embolism and realise that it can masquerade as many other illnesses”

33. THANK YOU