PBL CASE PRESENTATION

Presenting Complaint 70yo female Presents to ED with sudden onset SOB, chest pain and haemoptysis. Unable to walk due to recent hip replacement surgery At ED, – BP  145/90 – RR  30 – Afebrile

History Past Medical History – Hypertension for 10 years – Appendectomy 30 years ago – Osteoporosis – Hip replacement surgery 3 weeks previously after FNOF Family History – Mother died of unknown cancer aged 73 – Father died of heart issues (unknown) – Children well Medications/Allergies – Tritace (ACE inhibitor) – Bisphosphonates – Calcium and Vitamin D supplements – No Known Allergies Social History – Previously smoked from ages (1 pack/day) – Social drinker (1 glass of wine/week) – Average diet – Nil exercise – Overweight – Lives with husband

Risk Factors Immobility – Yes, due to her recent hip replacement surgery Clotting disorders - Nil Recent injury – Yes, FNOF injury Recent surgery – Yes, as above Pregnancy – Not currently Past history/Family history – Nil Overweight/Obese – Somewhat overweight Smoking – Yes, previous smoking history OCP use – Nil Cancers – Nil

Immediate management Was given high flow oxygen. Started on LMWH due to history

Examination HR: 126 BP: 145/90 RR: 30 bpm Afebrile Auscultation – course crackles over R lower lobe. JVP – 5cm Cardiovascular exam normal

Investigation ECG –sinus tachycardia Troponin – normal. CXR – slight blunting of R costophrenic angle (NB: this usually occurs after some time). D-Dimer – positive V/Q scan – medium (chance of PE) Spiral CT scan with IV contrast performed – showed medium sized pulmonary emboli in R lower inter lobular artery.

NB: this scan would conclude high risk of PE.

a clot in the anterior segmental artery in the left upper lung

Diagnosis A medium sized pulmonary embolism most likely from a DVT, brought on by her inactivity following her hip replacement. Following her initial LMWH, she was started on oral warfarin.