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Post by DD on Sept 23, 2014 16:17:21 GMT -5
Patient is a 26 year old female with hemoptysis and sharp, pleuritic chest pain for the past 2-3 days. She states the pain is severe, stabbing, worse with deep breaths. She is 6 months pregnant and had a positive PPD 1 month ago with a negative chest x-ray. She states she was started on INH but she did not finish her course and missed some doses. She states she may have been exposed to TB in prison, she also has a history of asthma. She has a history of two prior misscarriages. After suiting up in your PAPR gear you assess the patient. Vitals: BP: 122/69 (Sitting), Pulse: 98 (Sitting), Resp: 24, Temp: 37.0 (Oral), Pain: 8/10, O2 sat: 98 on ra Exam: AA&Ox3, Moderate distress. Head: Normocephalic, atraumatic. ENT: Pharynx is clear, TM's normal. Neck: Soft and supple, trachea midline. Chest: Scattered Wheezes. Nontender. Heart: RRR, no murmur, gallop, friction or rub. Abdomen: Soft, NT, ND, normoactive BS. Ext: No edema. EKG:  |
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Post by Bjs04f on Sept 23, 2014 21:45:08 GMT -5
EKG isnt impressive, is the a CXR? Concerning things are pregnancy, failure of full TB treatment, and prior miscarriages. So is this reactivation of TB, PE, pericarditis with normalization of EKG, pneumonia, does she have lupus or auto immune disease based on miscarriages. Need more info,
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Post by DD on Sept 25, 2014 1:25:36 GMT -5
That's pretty much the same differential bruss and I came up with. How will you solve that?
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Post by Bjs04f on Sept 25, 2014 10:43:37 GMT -5
shoot the chest xray and get a cardiac panel first. Normal CXR and I can drop TB reactivation, normal cardiac panel with normal EKG lowers peri/myocarditis. If weve reached that point with everything normal its time to consider doing a CTA PE, can be done in pregnancy if necessary. D-dimer wont be helpful neither will doppler as DVT can be pelvic in pregnancy
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Post by pbruss on Sept 28, 2014 0:34:18 GMT -5
fyi-you can use a d-dimer to rule out PE/DVT in a pregnant lady. In the initial PIOPED study, pregnant women WERE included. D-dimer can be up due to pregnancy but not every pregnant has an elevated d-dimer. Thus a negative d-dimer is suffecient in a pregnant woman.
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Post by pbruss on Sept 28, 2014 0:48:30 GMT -5
fyi-you can use a d-dimer to rule out PE/DVT in a pregnant lady. In the initial PIOPED study, pregnant women WERE included. D-dimer can be up due to pregnancy but not every pregnant has an elevated d-dimer. Thus a negative d-dimer is suffecient in a pregnant woman.
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Post by Bjs04f on Sept 28, 2014 8:00:20 GMT -5
not saying you cant use a d-dimer, but in her case I didnt feel she was low risk enough that a negative d-dimer would allow me to feel comfortable saying this wasnt a PE. I only use d-dimer in low risk cases where Im confident that if negative I can be done, mod or high risk it isnt supposed to be used, and low risk negative perc it isnt used.
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Post by DD on Sept 28, 2014 8:35:07 GMT -5
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Post by Bjs04f on Sept 28, 2014 18:38:45 GMT -5
alrighty then
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Post by DD on Sept 30, 2014 18:28:43 GMT -5
What is that?
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Post by Bjs04f on Sept 30, 2014 20:03:12 GMT -5
hilar lymph node?
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Post by DD on Oct 1, 2014 14:47:59 GMT -5
So what does she have?
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Post by Bjs04f on Oct 1, 2014 17:53:15 GMT -5
sarcoid, lupus, cancer, its not specific to one thing. But based on histroy and presentation Lupus would be high up on list.
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Post by kemple on Oct 4, 2014 20:14:29 GMT -5
Strong work Stransky.
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Post by DD on Oct 5, 2014 14:25:05 GMT -5
Radiologist read it as several hilar nodules conistent with sarcoidosis.
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