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Discussion Starter · #1 ·
2 days after colectomy 55 year male pt complain of sudden onset of SOB ,difficulty breathing, on examnination -po2 55 pco2 23 ph 7.38, RR-28, O2 saturation 88
decrease breath sound on right, chest xray show atelectasis at both lung base.ecg shows non specific st-t wave changes..current medications are heparin,morphine, and hydrocholr thiazide
what is most appropriate next step after o2 therapy?

-ivc filter
-ct chest
-warfarin
-heparin
-pulmonary angiography

i am confused between ivc filter and ct chest..
 

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The most appropriate would be IV filters as the pt is already is distress and signs of PE are already present. If I remember right you always start treatment and then do the investigations.
 

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I don't think you can put ivc filter on clinical suspicion without confirming diagnosis...
so acc to me it should be ct.
That's what I think.
 

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Discussion Starter · #4 ·
The most appropriate would be IV filters as the pt is already is distress and signs of PE are already present. If I remember right you always start treatment and then do the investigations.
i also thought same ivc filter but some where i read ct chest to confirm diagnosis before doing any invasive procedure. so i was confused. but still i will go with ivc filter.
 

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Discussion Starter · #5 ·
yeah ..it is confusing question. and decision would be totally subjective .. some would prefer ivc to prevent future stroke as a preventive measure and some would prefer to avoid invasive procedure...so still confuse//:rolleyes:
 

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Inferior Vena Cava is the answer when:

1- there is contraindication to anti-coagulation eg. recent surgery, history of hemorrhagic stroke

2- History of complications from anti-coagulation eg. Heparin Induced Thrombocytopenia

3- Patients who develop recurrent DVT or pulmonary embolism despite receiving anti-coagulation

also it can be used it the PE was severe and the next one might turn out to be fatal
 

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Ds is obvious, thats why there is no need for CT. And this concept is written in MTB 3, frequently asked in UWQbank. First step - therapeutic dose of heparin.
Then may be pulm angio and trying to break the thrombus (MTB 3: if pt is unstable do thrombolysis or embolectomy). But in situation of liver hematoma after blunt abdominal trauma, they (MTB 3) tell to put vena cava filter, not heparin.
Colectomy with instrumental anastomosis is not so dangerous in the context of hemorrhage complications.
 

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the diagnosis is highly suspicious, but it's not confirmed, especially considering he's already on heparin. and the IVC filter is a really invasive thing. in the hospital I was working at least, they would kick you out
 

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the diagnosis is highly suspicious, but it's not confirmed, especially considering he's already on heparin. and the IVC filter is a really invasive thing. in the hospital I was working at least, they would kick you out
We are taking about USMLE here, not hospital realities.
 

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yeah of course, but it's at least somewhat based on real life practice/ medical evidence. my point is, putting an IVC without any real knowledge of what is going on in the vessels seems inappropriate to me
 

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On Updodate:

●The clinical presentation of acute pulmonary embolism (PE) is variable and nonspecific; thus, diagnostic testing is necessary to either confirm or exclude the diagnosis of PE. (See 'Introduction' above.)

●The major diagnostic tests employed in the evaluation of a patient with suspected PE include computed tomography pulmonary angiography (CT-PA), ventilation-perfusion (V/Q) scanning, D-dimer testing, ultrasonography, and conventional pulmonary angiography. (See 'Diagnostic tests' above.)
 
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