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What’s the Diagnosis #18

A 51 year old male presents with chest pain and exertional dyspnea for the past 24 hours which began a week after having a trimalleolar ankle fracture repaired.

Chest x-ray shows a right middle lobe infiltrate. WBC is 18.2. CPK is 180 (normal). Troponin is 0.9 (cutoff for acute MI is 0.64).

EKG is shown below (you can click on the image for a larger view).

What’s the diagnosis? What is the treatment?

Answer will be posted in the comments section in a couple of days.

What's The Diagnosis #18 EKG

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10 comments

  1. Pulmonary embolus.

  2. Diagnosis: PE.
    Treatment: CT angiography, afterwhich anticoagulation treatment (probably with LMWH, warfarin or acenocoumarol) and either thrombolysis or a pulmonary thrombectomy should be commenced.

    This presentation is highly suggestive of ACS, although the recent surgery and immobilization the probably followed are in favour of PE.
    The ECG is significant for Sinus Tachycardia, S1Q3T3 and T-wave inversion in V1 (and maybe a hint of pulmonary P waves?), that together are relatively predictive of an APE.
    I would also perform a D-Dimer and a coagulation profile (prior to the commencement of the anticoagulation therapy, of course), and admit for further observation at the pre-op or internal departments.

    • If you are going to perform the CT angio then there is no reason to do a ddimer.

      • A D-Dimer would be among the first battery of tests, including a troponin and coag. profile. CT Angio is dependent upon availability of staff and equipment.
        If a D Dimer would come back as negative the angio can be called off, and other reasons of cor pulmonale should be investigated.

  3. Sounds like a PE to me.

  4. Just the history and the CXR made the dx for me. EKG confirmed.

  5. s1q3t3; couldn’t bring up the CXR. Don’t practice in Georgia and miss this diagnosis.

  6. I was thinking PE – could it be a fat embolus? I knkow that that’s usually associated with a femur fracture/large bone fracture but does it differ?

    As for Tx – oxygen, I’ve been educated that if it’s an air embolus to put the pt in the Lt side lying trendelenburg position to try to trap it in the right ventricle and prevent travel to the lung – tho I’m assuming that this has already travelled to the lung (wasn’t able to pull up the x-ray) therefore I would put the pt in high fowlers to ease breathing. Draw labs (PT, PTT, INR, D-dimer – ABG) and start anticoag therapy (most likely a heparin drip) – considering he just had his fracture set – I might not suggest a clot buster since this would increase his risk of bleeding even more – I’d say the risks of bleeding outweigh the benefit so long as the anticoag therapy is effective and pt responds in a timely manner to this). Though the ECG shows that his heart is stressed due to the PE – so if the pt does NOT respond quickly and the ECG continues to show the sinus tach or goes on to right bundle branch block or right axis deviation I would then introduce the clot buster because then it would certainly be required.

    I hope this makes sense.

  7. I would also work up the possibility of pulmonary embolism, and treat accordingly.

  8. You’re all too damn smart.
    Infiltrate on the x-ray was a pulmonary infarction, not a pneumonia.
    Pulmonary embolism it is.
    Note that the EKG shows an S1Q3T3 pattern — a wide deep S wave in lead I, an isolated Q wave in lead III, and an inverted T wave in lead III. The S1Q3T3 pattern is a sign of acute cor pulmonale. It is rather nonspecific for PE, occurring in only 11% to 54% of documented pulmonary emboli, but when present, one Polish study showed that the S1Q3T3 pattern is associated with acute pulmonary emboli in 74% of cases and has a positive predictive value of 80% for pulmonary embolism.
    Bottom line is don’t use absence of an S1Q3T3 pattern to exclude a pulmonary embolism, but consider pulmonary embolism (and other potential causes of cor pulmonale such as pneumothorax) when you see the pattern.

    Want a good mnemonic for pulmonary embolism risk factors?
    “MOIST CAMEL”

    Mobility (decreased due to surgery, paralysis, bed rest)
    Obesity
    Insulin
    Smoking
    Trauma

    Clotting disorder
    Age >50
    Malignancy
    Estrogen excess/pregnancy
    Long bone fracture (fat emboli)

    I have another good case involving a bariatric surgery patient I’ll put up next week that won’t be so easy … then we’ll see who gets crowned Mr. Smartypants of the Whitecoatosphere.

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