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MANILA DOCTORS HOSPITAL

Department of Internal Medicine


United Nations Avenue

CCU Conference

Blue and Red Turning Against You


Pulmonary embolism

April 4, 2017
12:00NN -2:00 PM
MBFI Hall
Manila Doctors Hospital

Reporter:
Olivia Faye J. Listanco
3rd Year Medical Resident

Reactors:
Dr. Dante Morales Dr. Virgilio Banez
Dr. Elaine Alajar Dr. Luminardo Ramos
Dr. Elmer Llanes Dr. Gino Quizon
Dr. Ian Estanislao Dr. Des Roman
Dr. Albert Albay Dr. Ronald Santos
Dr. Noel Viado Dr. Arlene Afaga

Moderator:
Dr. Marjorie Obrado

CASE PROTOCOL
General Data: This is a case of DD, a 47-year- old female, married, Catholic, unemployed from Tondo, Manila.
Chief Complaint: Shortness of breath

History of Present Illness:


Patient had a one year history of abnormal uterine bleeding characterized with 2-3 fully soaked pads per day at 4-
6 days but associated dizziness, loss of consciousness or difficulty of breathing. Patient was previously admitted last
1/15/2017 for an elective TAHBSO. Patient cardiopulmonary risk stratification done as outpatient was low risk to develop
CP complications in an intermediate risk procedure (Revise Cardiac Risk Index: very low risk; 0.4%). She underwent Total
Abdominal hysterectomy with bilateral salphingoophorectomy last 1/16/2017, and procure was uneventful.
One day post op (1/17/2017), patient reported to have one episode of loss of consciousness lasting few seconds.
Patient was referred to cardiology service and work up was suggested. Patient was eventually discharged stable.
Interim, patient had shortness of breath (SOB) and easy fatiguibility on walking short distances (3 steps) but was
relieved with rest. No reported profuse bleeding at the post-operative site or vaginal in origin. No consult done.
One day PTA (1/20/2017, 4th day post op), patient had recurrence of SOB hence patient initially sought consult at
USTH and O2 support was given which afforded minimal relief, She was advised admission for work up but opted for
DAMA.
Day of admission, patient sought consult at OGC and 2decho was done at the heart station as outpatient.
At home patient has worsening of SOB at minimal exertion and was brought to Marys Child Hospital but eventually THOC
to MDH.

Review of Systems:
General: (-) fever (-) weight loss
HEENT: (-) retro orbital pain, (-) diplopia
Respiratory: (-) intermittent cough, (-) hemoptysis, (-) dyspnea
Cardiac: (-) chest pain (+) lightheadedness/ dizziness (-) bipedal edema
GI: (-) diarrhea, (-) constipation, (-) hematochezia, (-) melena
Genitourinary: (-) dysuria, (-) hematuria, (-) discharge, (-) decrease in UO
Neuro: (-) seizure, (-) dizziness, (+) loss of consciousness

Past Medical History:


Denies diabetes, hypertension or bronchial asthma
No allergies
No previous MI/ stroke

Personal and Social History:


Unemployed
No vices
Denies history of illicit drug use
Baseline functional capacity: Able to do activities if daily living independently. He denies failure or anginal symptoms.

Physical Examination on Admission


General: Conscious, coherent, in mild respiratory distress relieved with O2 supplementation
Vital Signs: BP 100/70 HR 122 RR 28 Temp 36.0C O2sat 99% at 2lpm
HEENT: Anicteric sclerae, pink palpebral conjunctivae, (-) neck vein engorgement, no cervical lymphadenopathy
Respiratory and Chest: Equal chest expansion, clear breath sounds
Cardiac: Adynamic precordium, tachycardic rate, regular rhythm, distinct S1/S2, PMI at 6th ICS, left anterior axillary line;
no murmurs
GI: Incision site with well apposed edges, no active bleeding, discharge, redness or hematoma seen, soft, non-tender,
flabby abdomen, (-) palpable masses
Extremities: (-) bipedal edema, no cyanosis
Neurological Exam: unremarkable

Course at the ER:


(11/22/16)
At the ER, patient was seen in mild respiratory distress, tachycardic but with normal blood pressure and spot O2
saturation. Two-dimensional echocardiogram done showed initial reading of dilated right atrium and ventricle with reduced
systolic function and signs of pressure and volume overload. Twelve-lead ECG showed sinus tachycardia, incomplete
right bundle block and high lateral wall ischemia, with no signs of RV dilatation. Other laboratory tests revealed
leukocytosis wit neutrophilic predominance on CBC and pyuria with bacteruria on routine urinalysis. D-dimer test done
had normal result. Initial impression was pulmonary embolism probably secondary to immobilization (post-surgery), rule
out hypercoagulable state, urinary tract infection, myoma uteri; S/P TAHBSO (10/10/16).
Patient was admitted at the medicine ward under the cardiology and gynecology services, and referred to the
vascular cardiology service. Oxygen supplementation at 2lpm which afforded minimal relief from SOB was given. Heparin
drip was also started at Heparin 4800 units IV bolus and maintained at 18 units/kg/hour, initially. Clindamycin, omeprazole
and iron supplementation were continued.

(11/23/16)
On second hospital day, patient was less dyspneic and no bleeding episode was reported however she had
complaints of epigastric pain. She had stable vital signs. Vascular cardiology inputs included a consideration of acute high
grade pulmonary embolism secondary to immobilization/ surgery; rule out hypercoagulable state; acute stress gastritis.
Serial partial prothrombin time tests were done and the Rashke protocol was used for the titration the maintenance dose
of the heparin. The target PTT ratio was 1.5-2.0. Initial CT angiogram was contemplated for the patient but due to
unavailability of the imaging study at that time, pulmonary angiogram was instead contemplated. Omeprazole was also
increase to 40mg/tab BID. Bilateral venous Doppler study of the extremities was also requested.

(11/24/16)
On the third hospital day, patient had minimal complaints of SOB and with stable vital signs. Heparin drip was on
hold and patient underwent pulmonary angiogram with possible catheter directed thrombolysis. Tolerated the procedure
and imaging study done showed left pulmonary artery (superior segment) and right pulmonary artery (superior segment)
lling defect and rest of the branches showed no signicant lling defects. Findings strongly indicated right and left
pulmonary arterial embolism and elevated main pulmonary arterial pressure. Patient then was transferred to the CCU for
systemic thrombolysis.
At the CCU, patient had had stable vital signs but still dyspneic. Systemic thrombolysis was started with
streptokinase 250 000 units IV bolus for 30 minutes, the maintained on 100 000 units/hour for 24 hours. Hydrocortisone
100mg IV was also given as pre-medications. Patient had low grade fever during infusion. No reported bleeding episodes,
or abdominal pains was made.

(11/25/16)
On the fourth hospital day, patient had improved dyspnea and rest of vital signs was normal. Patient still had in
going streptokinase drip. Patient had minimal bleeding at the venipuncture site which resolved with pressure dressing.

(11/26/16)
On the fifth hospital day, patient had no complaints of dyspnea, fever, or bleeding but had persistent non-
productive coughing. Vital signs were stable. On physical exam she developed crackles on the right mid to base lung.
Repeat laboratory tests were done. CBC showed increased levels of leukocytosis (WBC 13.63 16.68) and neutrophilic
predominance (Neutrophils 73 85). Chest x-ray done however showed no active infiltrates. Repeat urinalysis showed no
improvement in the degree of pyuria and bacteria as well. Hospital acquired pneumonia and complicated UTI were
entertained. and she was referred to infectious disease service. Sputum culture was done and Clindamycin was initially
shifted to Levofloxacin 500mg tab OD then to Piperacillin tazobactam 4.5gm IV Q8.
PTT ratio was 1.11 and Enoxaparin 0.6cc SQ Q12 was started. She was also the transferred to the female
medicine ward.

(11/27/16)
On the sixth hospital day, patient still had coughing episodes but no recurrence of fever. Tachycardia was also
noted at 90-110s and she was started on Lanoxin 0.25mg/tab OD. Piperacillin tazobactam for the HAP and for the PE
Enoxaparin were continued and overlap of Warfarin 2.5mg/tab 1 tab ODHS was started too.

(11/28-29/16)
On the seventh and eighth hospital day, patient had stable vital signs. Antibiotics and anticoagulants were
continued. Histopathologic report for the TABHSO done showed no indication of an active malignancy. Patient was able to
tolerate a 6minute walk with no complaints of difficulty of breathing.

(11/30/16-12/1/16)
On the ninth hospital day, patient had no subjective complaints and vital signs were normal. Repeat CBC showed
improved leukocytosis and for the HAP and UTI, Piperacillin tazobactam was shifted to Levofloxacin 750mg/tab OD.
PT/INR was 1.22 (Target= 2-3), hence discharged was deferred and warfarin was increased to 2.5mg 1 tab ODHS and
enoxaparin was continued. Ambulation was encouraged and continued.
Tenth hospital day was uneventful.

(12/2-3/16)
On the eleventh hospital day, patient had no subjective complaints and vital signs were normal. Repeat CBC
showed further improvement on the resolution of infection. PT/INR was 1.52 and warfarin was increased to 5mg/tab
ODHS and enoxaparin to 0.8cc SQ ODHS (1.5mg/kg/day).
Twelfth hospital day was uneventful.

(12/4/16)
On the thirteenth hospital day, patient had stable vital signs. Repeat PT/INR was 2.1, and enoxaparin was
discontinued. Patient was discharged with following medications, Warfarin 5mg, 1 tab OD, Lanoxin 0.25mg OD, and
Levofloxacin 750mg OD to be completed for 7 days (11/5/16).

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