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January 2016: Lung

A 57-year-old female chief cook reports to the clinic complaining of coughing with progressively worsening shortness of breath. She first developed shortness of breath as she arrived on the rig from her 2-hour helicopter flight. She felt winded after walking up the deck stairs but dismissed her symptoms as a cold, starting with a cough, as her 2-year old daughter recently was treated for bronchitis. She notes that the cough is intermittent and productive with pink sputum. The cough has been worsening over the last 3 days. The patient notes that she was trying to get some rest and did take 24 hours off of her tour; she was having difficulty breathing while lying down to sleep.

She denies chest pain, dizziness, fever, headache, vision changes, or abdominal pain.

  • Past Medical History: hypertension, obesity, fibrocystic breast disease
  • Past Surgical History: hysterectomy, breast biopsy
  • Current Medications: lisinopril-hctz 40mg/25mg daily, atorvastatin 20mg daily
  • Allergies: NKDA
  • Immunization Status: Up to date including annual flu vaccine
  • Social History: Social drinker, smokes 1 pack a day for 45 years
  • Family History: Mother died at 72; father died at 54 due to complications related to uncontrolled diabetes and hypertension

Vitals

  • Temp 99.1
  • Pulse 107
  • Respiration 25
  • BP 142/86
  • POx 94% on Room Air
  • Weigh: 270 lb, BMI 44
  • Height: 5’6”

Physical Exam

  • General: A&Ox3, obese female, sitting on the exam table, appears uncomfortable
  • HEENT: PERRLA, EOMI; TM’s appear normal, throat normal, sinuses are non-tender to palpation
  • Neck: soft, trachea is midline, neck veins appear engorged
  • Cardio: tachycardic, regular rhythm, no murmurs appreciated
  • Lung: tachypneic, clear to auscultation bilaterally
  • Abdomen: protuberant, soft, non-tender, non-distended, normal bowel sounds
  • Extremities: no clubbing, cyanosis or edema, good peripheral pulses, mild TTP to L posterior lower extremity
  • Neuro: Cranial nerves II-XII grossly intact, CN IX-X are not tested

Lab Work

Urine Analysis

  • Color – dark yellow
  • Clarity – clear
  • Specific gravity – 1.020
  • pH- 7.0
  • Glucose – negative
  • Bilirubin – negative
  • Blood – negative
  • Urobilinogen – 0.2 EU
  • Protein – 1+
  • Ketones – 10+
  • Nitrite – negative
  • Leukocyte esterase – trace

How would you approach this patient?

Differential Diagnosis

  • Upper Respiratory Infection
  • Heart Failure
  • Myocardial Infarction
  • Pulmonary Embolism
  • Pleuritis

Diagnosis: Pulmonary Embolism

 

Treatment:

  • IV fluid for volume support
  • Adjuvant therapy: Oxygen via nasal cannula or mask
  • Ensure patient comfort
  • MEDEVAC ASAP

Discussion:

When dealing with patients with potential pulmonary embolism (PE), it is very important to first determine your index of suspicion for the likelihood that your patient has a PE. Some concerning clinical indications that increase the risk for PE include leg swelling or leg tenderness with palpation, tachycardia, hemoptysis, immobilization or history of recent surgery, history of malignancy or when diagnoses other than PE are less likely. Other risk factors for PE may be present as in this patient’s case, obesity, hypertension and heavy tobacco use.

In patients with high or moderate probability of having a PE, anticoagulation should be administered as soon as possible provided the risk of bleeding is low. In the industrial remote environment one cannot assume that transportation to a higher level of care for clinical evaluation and confirmation of PE will be readily available within 24 hours. Once the patient arrives to the higher level of care, several tests may be performed to confirm your clinical suspicion for PE. Testing may include x-ray, D-dimer blood test, CT angiogram, pulmonary angiogram, or ventilation/perfusion scan. Initiation of anticoagulation will need to be determined on a case-by-case basis. In cases with a high index of suspicion, anticoagulation is initiated with medications such as unfractionated heparin, lower molecular weight heparin, or a factor Xa inhibitor. If there are contraindications to anticoagulation, other treatments such as thrombectomy (surgical removal of a blood clot) or placement of an inferior vena cava (IVC) filter may need to be considered.

The return to the industrial remote environment will need to be determined on a case-by-case basis. Patient/employee safety is very important and multiple considerations must be made regarding the risk to the individual as well as to the employer. The risk of recurrence, specific therapies, duration of treatment, and stability on medications need to be determined prior to the patient returning to work.

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