Вальсальва

36 years old man came to medical award because of strong chest pain in the infrascapular region on the right side of the chest. Pain from the last 4 days. Pain increases on inspiration and palpation. On admission temperature 38.1 C. No cough , no dyspnea. No legs swelling. In god shape. Previously healthy man. Smoker. Puls 75/min. BP 120/80. God pO2, pCO2 and pH. On auscultation crackles and wheezing bilaterally but more on the right side. I took rtg thorax, lab. examination and echocardiography and lungs UL. Is it all right with echo? What is presumptive diagnosis? What kind of treatment? What kind of further testing?

UL and echo

xyz

yzx

Kidney and gallbradder 1.

Kidney and gallbladder 2.

and?
The next is spleen?
waiting

Looks like pleurisy, not sure about pneumonia: lung tissue doesn't look consolidated.
So will try to treat him with NSAIDS and look. Not sure about antibiotics: no infiltration on chest x-ray, no signs of severe infection.

CRP 102 mg/l!!!
Bacterial pneumonia is more likely.
There are pulmonary consolidation and pleural effusion at the images and videos.
Antibiotic must be prescribed.
Were Lung CT, D-dimer, deep vein ultrasound performed?

Pyankov Vasily писал(а): ↑

Ср сен 19, 2018 12:19 am

CRP 102 mg/l!!!
Bacterial pneumonia is more likely.
There are pulmonary consolidation and pleural effusion at the images and videos.
Antibiotic must be prescribed.
Were Lung CT, D-dimer, deep vein ultrasound performed?

High CRP doesn't discriminate between viral and bacterial infection.
Consolidation is very subtle if present at all, not even seen on X-ray.
No respiratory distress, no tachycardia or hypotension. If it is pneumonia it is very low risk one.
So I would not prescribe antibiotics just because of CRP.
Pulmonary embolism can be the cause of pleuritic chest pain and considering age I would take D-dimer and perform compression ultrasound of deep veins. CT? Not sure.

Because of shortened AccT and double shaped flow in RVOT, and TR gradient of 33mmHg and also rapid regurgitant jet in PA , I decidet to take veins UL. This is left popliteal vein

Is there any thrombus higher?
Femoralis or illiac vein?

Wojtek Guzowski писал(а): ↑

Ср сен 19, 2018 9:09 am

Is there any thrombus higher?
Femoralis or illiac vein?

I have not found

Wojtek Guzowski писал(а): ↑

Ср сен 19, 2018 9:09 am

Is there any thrombus higher?
Femoralis or illiac vein?

I am not so sure about double flow in PA: you should have really significant PE to have this.
I would rely more on clinical suspicion than on echo. And how huge PE was on CTA?

AOkhotin писал(а): ↑

Ср сен 19, 2018 1:01 am

Pyankov Vasily писал(а): ↑

Ср сен 19, 2018 12:19 am

CRP 102 mg/l!!!
Bacterial pneumonia is more likely.
There are pulmonary consolidation and pleural effusion at the images and videos.
Antibiotic must be prescribed.
Were Lung CT, D-dimer, deep vein ultrasound performed?

High CRP doesn't discriminate between viral and bacterial infection.
Consolidation is very subtle if present at all, not even seen on X-ray.
No respiratory distress, no tachycardia or hypotension. If it is pneumonia it is very low risk one.
So I would not prescribe antibiotics just because of CRP.
Pulmonary embolism can be the cause of pleuritic chest pain and considering age I would take D-dimer and perform compression ultrasound of deep veins. CT? Not sure.

Артемий! В наших реалиях меня бы четвертовали, если бы я не назначил данному пациенту антибиотики. Конечно я сразу подозревал у него ТЭЛА и инфаркт легкого. У нас "инфаркт-пневмонии" без антибиотиков к сожалению не лечат...