Pulmonary Embolism

1. CASE PRESENTATION ON PULMONARY
EMBOLISM
Dr .Md.Rashedul Islam
Senior Medical Officer (MICU )
Evercare Hospital Chittagong

2. PATIENT PROFILE:
Name: Mrs. KAMRUNESSA BEGUM
Age: 79 years
Sex: Female
Address: SUGONDA R/A AREA, , CHATTOGRAM
Religion: Islam
Date of Admission:02/07/2021 8:53AM
Date of discharge:10/07/2021

3. CHIEF COMPLAINS:
• 1.Respiratory distress for 4 Hours
• 2. Pain in the Right Lower Abdomen for 1 day

4. HISTORY OF PRESENTING ILLNESS:
• According to the statement of the patient’s son patient was relatively well 1day back, since then
patient develops pain in the right side of the lowed abdomen . Pain was intermittent, sharp, and
radiating to the back. Pain was associated with anorexia and nausea but not associated with
vomiting or diarrhea. For last 4 hours patient develops sudden respiratory distress which was
progressively increasing . There was no history of fever ,chest pain, hemoptysis, cough or swelling in
the leg

5. HISTORY OF PAST ILLNESS:
Patient had H/O Covid-19 Pneumonitis last year & was admitted in to ICU of CMCH
She had H/O Acoustic Neuroma (operated) on 1999
H/O CVD followed by VP shunt on 2000.
Patient is Diabetic and Hypertensive for 6 years,
Asthmatic for 3 years
H/O HIP prosthesis surgery for two time in the year of 2000 and 2005
2˚ Hemorrhoid
OSA /Pickwickian Syndrome

6. FAMILY HISTORY
Nothing significant
PERSONAL HISTORY
Patient is non-smoker, Non-alcoholic and non-betel nut chewer

7. DRUG HISTORY
She took Insulin ,Tablet Amlodipine, Bisoprolol, Risperidone, Escitalopram

8. GENERAL EXAMINATION
• Patient was dyspneic and anxious looking
• Morbid obesity
• Decubitus was on her choice
• No Anemia, Jaundice,Cyansis,edema,clubbing,Koilonychea or leukonykia was present
• Pulse-78b/m
• BP-140/90 mm of hg
• Respiratory Rate- 24 b/m
• Temperature-98F

9. GENERAL EXAMINATIONS:
PBW.: 110 KG BP:140/90 mm HR: 78 B/min.
Temp.: 98 Normal
ANAEMIA/JAUNDICE/CYANOSIS
/EDEMA- ABSENT
DEHYDRATION,CLUBBING,
KOILONYCHWEA/
LlEUKONYCHEA were Absent

10. CNS:
• GCS-E3M6V5(14/15)
• Pupil – Normal reacting to light
• M/P – 3/5 in all 4 limbs.
• Neck rigidity – absent
• Planter- equivocal (B/L)
HR-78b/m , Rhythm was sinus
Heart sound-S1+S2+0
No murmur or added sound was
present
CVS:
SYSTEMIC EXAMINATION

11.  RESPIRATORY SYSTEM:
• Breath Sound was VESICULAR type bilaterraly
• Fine crepes was present on both lung field
 GIT :
• Abdomen was soft ,nontender
• Bowel Sound was present,
• no palpable organomegaly found
• Foley Catheter was done in ER
>Other systems reveals no significant findings.

12. ROUTINE INVESTIGATION
Investigations Normal
Range
Date/Time Date/Tim Date/Time Date/Time Date/Time
ABG
FiO2
pH
7.35-7.45
PaCO:z
37-45mmHg
PaOz
80-90mmHg
SaO2
94-97%
HCOa
24-32

13. Electrolyte
Na+
135-145 mmol/L 138 140 148 148 144
K+
3.5-5.0 mmol/L 3.97 4.96 4.8 4.7 4.3
CI - 97-108 mmol/L 106 108 108 104 101
HCO3- 24-32 mmol/L 24 24 25 26 24
Parameter Normal range 2/7/2021 3/7/21 3/7/21 6/7/2021 7/7/21

14. 4th July
2th July

15. 7th july 8th july

18. ON HRCT
Impression:
• Status post Covid pneumonic changes
• Bilateral mild diffuse non-specific pneumonitis (CO-RADS – 3 score ,<5 % involvement )
• Right sided mild pleural effusions.
• Bilateral mild pleural thickenings

19. • TROPONIN-I > 5.97 ng/L
• SERUM-FERRITIN > 54.4 ng/ml (15 - 150)
• CRP >15.78 mg/dl (<.50)
• PROCALCITONIN > 0.36 ng/ml (0 < 0.05)
• D-Dimer > 3082 mcg/L (<500)
• Urine profile > Pus cell : plenty/HPF,RBCs : 5-15/HPF
• S.CREATININE > 0.60 mg/dl (2/7/21)
> 0.90 mg/dl (5/7/21)
> 0.80 mg/dl (6/7/21)
• TSH >0.23 µIU/ml (0.4 - 5.3)
• SERUM UREA > 50.0 mg/dl
• Echo > Normal
• Serum Albumin >2.6 g/dl
• Serum Calcium >7.0 mg/dl
• SERUM-MAGNESIUM >2.43 mg/dl

20. CBC
Hct. 36-45%
Hb 12.16 gm/ml
TLC 400-11000 cmm
Neutrophil 40-78 %
Lymphocyte 20-40 %
Eosinophil
2-10 %
Basophil
1-6 %
Monocyte 0-1 %

21. DIC PROFILE (PT ,APTT, FIBRINOGEN, D-Dimer)
• PROTHROMBIN TIME (PT& INR):
Control 12.0 s
Patient 12.8 Seconds (9.8 - 12.1)
INR 1.07
• APTT
Control : 30.0 s
Patient :36.6 Seconds (25 - 31.3)
• FIBRINOGEN LEVEL
Fibrinogen :188.5 mg/dl (180 - 350)
• D-Dimer
D-Dimer: 2579 µg/L < 500

22. THROAT SWAB C/S- ACINETOBACTER BAUMANNII
URINE C/S – NO GROWTH FOUND
BLOOD C/S –NO GROWTH FOUND

23. ULTRASONOGRAM OF WHOLE ABDOMEN
Comment
• Mild fatty changes in liver and hepatic calcification in right lobe.
• Bilateral renal parenchymal changes.

24. RIGHT LOWER EXTREMITY ARTERIES COLOUR DOPPLER
IMPRESSION:
• Mild diffuse atherosclerotic changes involving right lower extremity arteries.
• Normal good triphasic flow pattern in right lower limb arteries.

25. LEFT LOWER EXTREMITY ARTERIES COLOUR
DOPPLER
IMPRESSION:
• Mild diffuse atherosclerotic changes involving left lower extremity arteries.
• Normal good triphasic flow pattern in left lower limb arteries.

26. LEFT LOWER LIMB VENOUS COLOUR DOPPLER STUDY
IMPRESSION:
No Doppler evidence of deep vein thrombosis in left lower limb

27. RIGHT LOWER LIMB VENOUS DOPPLER
STUDY
IMPRESSION:
No Doppler evidence of deep vein thrombosis in right lower limb.

28. MANAGEMENT
As per Clinical and Rediological and lab findings the following mentioned treatment was given
• 1.Stat LMWH (60 unit 12 hourly)
• 2.Epmperical antibiotic therapy
• 3. Regula Antihypertensive Medication
• 4. Regular Lipid lowering agent
• 5.Regular antidiabetic Medication
• 6.Nebuligation with bronchodilators and Steroid
• 7.Mechanical DVD pump
• Additional Mx- Regular chest and limb physiotherapy , Nutritional support along with Proper
Nursing care

29. CASE SUMMARY
Mrs Kamrunessa, 79-year female came to our ER on 02July’Morning @ 8:40AM with the complains of pain in the abdomen located right side, for last
one day; her pain was sharp in nature & radiate to the back & it’s not associated with vomiting & alter bowel movement but associated with
Anorexia. But she developed resp. distress last 4 hours, for that reason her attendant admitted her in the EHC.
She had h/o Covid-19 Pneumonitis last year & admitted in to CMCH ICU. There she had h/o Per Rectal bleeding & dx for 2˚ Hemorrhoid.
She had h/o Acoustic Neuroma (operated) on 1999 & h/o CVD followed by VP shunt on 2000. She had also h/o Hip Prosthesis two times at year of
2000 & 2005. She was hypertensive & diabetic for last 6 years on medication. She was on medication for Asthma for last 2-3 year.
After admission in the EHC, initially primary assessment done at ER; after that she shifted to the yellow zone. As Rt-PCR came (-)ve, so pt shifted to
the MICU for further management. During admission pt was semiconscious & drowsy, GCS: E2+V3+M5=10/15; BP: 150/100 mmHg; SpO2: 98% with
O2 5l/min & pt was afebrile.
In MICU secondary review had done & Internist & Pulmonologist visited the pt & they suspected Pulmonary Embolism as Well’s Score: 4.5
(moderate risk); Revised Geneva Score: 4 (moderate risk) & 2 Criteria meet in PERC rule. So immediate Brain CT excluded & Pulmonary CT
Angiogram had done which reveals Right middle lobe Arterial embolism. So LMWH was started immediately. As patient had T2 Respiratory failure
with Resp. acidosis so NIV had started. In next day morning a combined medical board had arranged regarding the review treatment options, which
consists: Internist/Intensivist; Neurosurgeon; Cardiologist; Cardio-vascular surgeon; Pulmonologist & Orthopedic consultant. The medical board
advice the continue the present treatment & checkout the other etiology. After finishing the 10 doses of LMWH, oral anticoagulant had started. In
while patient need NIV(Bipap); which switch to CPAP later on.

30. MEDICAL BOARD OPINION
A medical board was held on 3/7/2021at 3.30pm consisting consultant of Critical care medicine, ,Internal Medicine ,
Respiratory Medicine, Cardiology , Vascular surgery and General surgery
Dx- Type-II Respiratory Failure due to Acutee pulmonary Embolism with OHS due to morbid obesity with DM with
H/O V-P shunt , 2* Hemorrhoid and U-V prolapsed
Medical board decision :
1.Target INR-2 to 2.5
2.Routine check- PT, APTT, CBC, Electrolyte, Creatinine, CxR, ECG
3.ABG 4 hourly
4.BiPAP-1st day 24 hour,2nd day 18 hours then according to patient requirement
5.Stop DVD pump
6.Antibiotic changed to Ertapenem from Fimoxyclav
7.I/V Fluid : H/S- 1500ml + N/S 500 ml daily

31. TOTAL HOSPITAL COURSE
Patient was admitted in ER on 02.07.2021 @ 8.40 am
Patient was shifted to Yellow Zone on 02.07.2021 @ 8.53am
Patient was shifted to HDU , After RT-PCR comes negative on 02.07.2021 @ 4.00pm
Patent was Step downed to Cabin on 8.07.2021 @ 1.00 pm
Patient was discharged from the Hospital on 10.08.2021@12.49pm

32. DISCHARGE
• Patient was discharged form the hospital on 10.07.2021 @ 12.40pm
• During Discharge patient condition was improved and cured