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Clinical Vignette thread

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Reply 160

Ghotay

Original post by Etomidate

No Hx of aspirin overdose.

Wells for PE: 4.5 (moderate)
D-Dimer: 680

CTPA please

Reply 161

Etomidate

Original post by Ghotay

CTPA please

Shows a segmental filling defect.

Plan?

Reply 162

Asklepios

Original post by Ghotay

Do a Wells score for PE before the d-dimer

I don't even know what that is, but yeah just started clinical years :tongue:

Reply 163

ForestCat

Original post by Etomidate

Shows a segmental filling defect.

Plan?

I'm Assuming that means PE.

Unless any contraindications start anticoagulation. Warfarin or NOAC?

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Reply 164

Etomidate

Original post by Asklepios

I don't even know what that is, but yeah just started clinical years :tongue:

Basically a scoring system to validate the use of d-dimer in ruling out a PE.

If someone is a low risk wells score, you can do a d-dimer. If it's negative, it's not a PE.

If someone has a high wells score, you just do a CTPA.

Reply 165

Etomidate

Original post by ForestCat

I'm Assuming that means PE.

Unless any contraindications start anticoagulation. Warfarin or NOAC?

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No contraindications. Do you want to give him anything in the mean time while his INR comes into range?

Reply 166

username1044510

LMWH.

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Reply 167

ForestCat

Original post by Etomidate

No contraindications. Do you want to give him anything in the mean time while his INR comes into range?

Local policy lmwh... Enoxaparin etc

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Reply 168

Asklepios

Continue oxygen, fluids etc
LMWH sc
Rivaroxiban / warfarin

Reply 169

Friar Chris

Original post by Ghotay

Do a Wells score for PE before the d-dimer

And then... order it anyway because 'PE top diagnosis or equally likely' (+3) is essentially automatically a 'yes' if you're doing the score, and the HR is 112? Wells score is fine and all, but if you're at the point that PE is at or near the top of your current differential then it's fairly irrelevant as it's always going to get at least 3 :flower:

For others for debate/educational value, imho Wells' Criteria (PE) have two main uses in practical reality:

1. When PE isn't a highly likely differential based on your clinical impression but because of diagnostic uncertainty you want to assess the risk with a score to see whether to investigate anyway

2. When writing a request card for a CTPA to make sure the radiologist accepts it :wink:

A&Es always go by score-based systems for defensive and protocol driven reasons (and still end up doing far too many inappropriate d-dimers), but a score is a tool, not a rule.

Reply 170

Ghotay

Original post by Asklepios

I don't even know what that is, but yeah just started clinical years :tongue:

The thing about d-dimers is that lots of things can raise it. So while it's good at excluding PE because if it's low it's definitely not that, if it's high it doesn't prove anything. Hence the wells score. It's not always useful because in the end you're going to follow your clinical judgement, but I agree with the above that it's a good defensive tool to defend why you DIDN'T get a CT

Would love some clarification on management - just realised I've never thoroughly been through what you give in what time frame, and what you send them home with

Reply 171

Asklepios

Original post by Ghotay

https://www.nice.org.uk/guidance/cg144/chapter/Recommendations#treatment-2

Reply 172

Etomidate

A 47yr old man with a previous history of gout, chronic lower back pain and high cholesterol presents to A&E with abdominal pain.

HR: 95
BP: 147/88
SpO2: 97%
T: 36.4
RR: 25

Reply 173

nexttime

Original post by Ghotay

The thing about d-dimers is that lots of things can raise it. So while it's good at excluding PE because if it's low it's definitely not that...

... except there is such a thing as a d-dimer negative PE. Which has a higher incidence in pregnant women (oddly, considering being pregnant is another reason for a high d-dimer).

Rare, and for gods sake don't CTPA everyone regardless of D-dimer as you'll be creating way more cancer than PEs you identify, but I have seen it when the clinical suspicion has been very high and they've done all the other tests and found nothing so did the CTPA which was positive. Just worth remembering.

Would love some clarification on management - just realised I've never thoroughly been through what you give in what time frame, and what you send them home with

Giving anticoagulation quickly will be the priority. And don't forget the cancer investigations.

When it gets very complicated is when they're pregnant. Or if they're haemodynamically compromised and people start using the 'thrombolysis' word!

Original post by Etomidate

No contraindications. Do you want to give him anything in the mean time while his INR comes into range?

Next question: how long you gonna keep him in hospital?

(edited 7 years ago)

Reply 174

Asklepios

Original post by Etomidate

A 47yr old man with a previous history of gout, chronic lower back pain and high cholesterol presents to A&E with abdominal pain.

HR: 95
BP: 147/88
SpO2: 97%
T: 36.4
RR: 25

Pain history - SOCRATES?

Standard GI hx = heartburn, reflux, nausea/vomiting, haematemesis, bowel motions

Reply 175

Kaylain

ABCDE as well please! Although those obs do look okay apart from the RR...

Also full abdo exam after the history

Reply 176

Brachioradialis

PMH (specifically HTN) + medications would be helpful too please :smile:

Reply 177

Etomidate

Original post by Asklepios

Pain history - SOCRATES?

Standard GI hx = heartburn, reflux, nausea/vomiting, haematemesis, bowel motions

Has been happening for 24hrs on left side of abdomen. Describes it as dull but can become sharp. It's not always there. Makes him vomit at its worst pain.

Denies reflux. Might been a few streaks of blood in one of the vomits. Can be constipated at times.

Original post by Kaylain