n*******c
发帖数: 501 | 1 （这个题目很知音，真烂，对不起）
是好久以前急诊夜班上发生的事。交班医生收了一个气促的病人，初步诊断是
exacerbation of pulmonary fibrosis，“这个病人很straightforward，老病号了，这次又是气促发作，收进来吸吸氧，你和呼吸科联系一下收入院吧。”交班医生简单的说道。
我看了一眼病历，果然老年女性病人，pulmonary fibrosis诊断好些年了，其间也住过几次院，好几封呼吸科医生有关治疗的信。
然后去看病人，非常可爱的老太太，可以看出很明显的气促，辅助肌呼吸，在2L的吸氧浓度下血氧勉强维持在90%，旁边陪着的是病人的女儿。
一问病史，才知道病人虽有P病多年，不过过去两三年都控制的不错，不需要吸氧，在家日常起居都很独立，今天据女儿说坐着好好的，突然一站起来就觉得呼吸困难，脸色都变了，没有明显的胸痛，觉得可能是老病发作，就赶快来医院了。
我看了一眼心电图，RBBB，一翻以前的病历，oh no…, 再一问病史，原来…
这时候上级医生来了，一看，赶快order一个Troponin, 果不其然，positive!
这个病人是要心内科急会诊吗？
不！,我坚定的说，我要一个CTPA，上级医生狐疑的看着我，然后我把原因一说，同意了。
CTPA显示双侧肺动脉主干栓塞，明显的Filling defect连我当时对CT不太熟都能看出来，然后不用多说，上LMWH。
这件事其实蛮简单的，不过这是当时位卑言低的我第一次对上级医生speak out and say no并且事实证明自己是对的，所以一直记到今天，算是信心低落时的治愈系记忆。
做医生其实真累，不过总有那么些瞬间让你觉得累也是值得的。
（版大，码字不容易，快发包子！） |
R*******t
发帖数: 367 | 2 我看了一眼心电图，RBBB，一翻以前的病历，oh no…, 再一问病史，原来…
What's missing here??
，这次又是气促发作，收进来吸吸氧，你和
【在 n*******c 的大作中提到】
: （这个题目很知音，真烂，对不起）
: 是好久以前急诊夜班上发生的事。交班医生收了一个气促的病人，初步诊断是
: exacerbation of pulmonary fibrosis，“这个病人很straightforward，老病号了，这次又是气促发作，收进来吸吸氧，你和呼吸科联系一下收入院吧。”交班医生简单的说道。
: 我看了一眼病历，果然老年女性病人，pulmonary fibrosis诊断好些年了，其间也住过几次院，好几封呼吸科医生有关治疗的信。
: 然后去看病人，非常可爱的老太太，可以看出很明显的气促，辅助肌呼吸，在2L的吸氧浓度下血氧勉强维持在90%，旁边陪着的是病人的女儿。
: 一问病史，才知道病人虽有P病多年，不过过去两三年都控制的不错，不需要吸氧，在家日常起居都很独立，今天据女儿说坐着好好的，突然一站起来就觉得呼吸困难，脸色都变了，没有明显的胸痛，觉得可能是老病发作，就赶快来医院了。
: 我看了一眼心电图，RBBB，一翻以前的病历，oh no…, 再一问病史，原来…
: 这时候上级医生来了，一看，赶快order一个Troponin, 果不其然，positive!
: 这个病人是要心内科急会诊吗？
: 不！,我坚定的说，我要一个CTPA，上级医生狐疑的看着我，然后我把原因一说，同意了。
|
A*******s
发帖数: 9638 | 3 Great writing! Baozi is on the way. lol
You are right on PE. But if I were you, I would let cardiology come anyway until PE is comfirmed. :)
，这次又是气促发作，收进来吸吸氧，你和呼吸科联系一下收入院吧。”交班医生简单
的说道。
过几次院，好几封呼吸科医生有关治疗的信。
氧浓度下血氧勉强维持在90%，旁边陪着的是病人的女儿。
在家日常起居都很独立，今天据女儿说坐着好好的，突然一站起来就觉得呼吸困难，脸
色都变了，没有明显的胸痛，觉得可能是老病发作，就赶快来医院了。
意了。
【在 n*******c 的大作中提到】
: （这个题目很知音，真烂，对不起）
: 是好久以前急诊夜班上发生的事。交班医生收了一个气促的病人，初步诊断是
: exacerbation of pulmonary fibrosis，“这个病人很straightforward，老病号了，这次又是气促发作，收进来吸吸氧，你和呼吸科联系一下收入院吧。”交班医生简单的说道。
: 我看了一眼病历，果然老年女性病人，pulmonary fibrosis诊断好些年了，其间也住过几次院，好几封呼吸科医生有关治疗的信。
: 然后去看病人，非常可爱的老太太，可以看出很明显的气促，辅助肌呼吸，在2L的吸氧浓度下血氧勉强维持在90%，旁边陪着的是病人的女儿。
: 一问病史，才知道病人虽有P病多年，不过过去两三年都控制的不错，不需要吸氧，在家日常起居都很独立，今天据女儿说坐着好好的，突然一站起来就觉得呼吸困难，脸色都变了，没有明显的胸痛，觉得可能是老病发作，就赶快来医院了。
: 我看了一眼心电图，RBBB，一翻以前的病历，oh no…, 再一问病史，原来…
: 这时候上级医生来了，一看，赶快order一个Troponin, 果不其然，positive!
: 这个病人是要心内科急会诊吗？
: 不！,我坚定的说，我要一个CTPA，上级医生狐疑的看着我，然后我把原因一说，同意了。
|
b******a
发帖数: 704 | 4 Thanks a lot for sharing.
Was it because a new onset of RBBB or LBBB? MI?
【在 R*******t 的大作中提到】
: 我看了一眼心电图，RBBB，一翻以前的病历，oh no…, 再一问病史，原来…
: What's missing here??
:
: ，这次又是气促发作，收进来吸吸氧，你和
|
y******a
发帖数: 590 | 5 Good catch. I had a similar case in my second year, an old pt presented
with acute worsening of SOB and newly onset Afib, also has pleural effusion
and recently diagnosed metastatic cancer. It was quite an argument between
me and ER physician, and finally they agreed to do a CT angio before they
signed out the patient to me. I was right, and the pt was taken by ICU in
the end. |
y******a
发帖数: 590 | 6 newly onset RBBB, PE should always be in the differential list.
【在 b******a 的大作中提到】
: Thanks a lot for sharing.
: Was it because a new onset of RBBB or LBBB? MI?
|
b***u
发帖数: 746 | 7 right, shall call cardiology no matter what, that's a protocol/legal issue
instead of pure medical issue, especially when you were just intern. Of course after your senior said yes it
became his responsibility, you should thank him for that:-)
Good catch indeed.
anyway until PE is comfirmed. :)
【在 A*******s 的大作中提到】
: Great writing! Baozi is on the way. lol
: You are right on PE. But if I were you, I would let cardiology come anyway until PE is comfirmed. :)
:
: ，这次又是气促发作，收进来吸吸氧，你和呼吸科联系一下收入院吧。”交班医生简单
: 的说道。
: 过几次院，好几封呼吸科医生有关治疗的信。
: 氧浓度下血氧勉强维持在90%，旁边陪着的是病人的女儿。
: 在家日常起居都很独立，今天据女儿说坐着好好的，突然一站起来就觉得呼吸困难，脸
: 色都变了，没有明显的胸痛，觉得可能是老病发作，就赶快来医院了。
: 意了。
|
b******a
发帖数: 704 | 8 Thank you!
【在 y******a 的大作中提到】
: newly onset RBBB, PE should always be in the differential list.
|
n*******c
发帖数: 501 | 9 不好意思，因为制造悬念需要，省略了部分情节。
问病史是关键，这个病人没有任何血管危险因素，从不吸烟，没有高血压、糖尿病、冠
心病病史，只有这个肺病，年轻时有一次postpartum DVT.
最近和人讨论，都说要合并CTCA和CTPA，的确见过几个病人两者都做，吃了不少射线和
造影剂的说，这个问题还请Rubyheart多多指教。
【在 R*******t 的大作中提到】
: 我看了一眼心电图，RBBB，一翻以前的病历，oh no…, 再一问病史，原来…
: What's missing here??
:
: ，这次又是气促发作，收进来吸吸氧，你和
|
n*******c
发帖数: 501 | 10 If it is not a typical STEMI for urgent angiogram, cardiology won't come
straight away and they will say call me when CTPA is done...
CTPA doesn't take much time and the patient was haemodynamically stable.If
cardiology came and review the patient it might delay the CTPA... Anyway...
since CTPA is very well under controll (as we are in ED, CT is just next
door and it only takes half an hour...)I don't think I would loss much by
calling cardiology after CTPA.
However this is really ED's call. I guess because cardiology usually assume
ED would exclude other possibilities and they don't think twice
when they get called by ED. So as a ED senior you have to know what you are
dealing with when you call them. IF, for me as a senior of other specialty,
I would request CTPA and ask for consult at the same time.
anyway until PE is comfirmed. :)
【在 A*******s 的大作中提到】
: Great writing! Baozi is on the way. lol
: You are right on PE. But if I were you, I would let cardiology come anyway until PE is comfirmed. :)
:
: ，这次又是气促发作，收进来吸吸氧，你和呼吸科联系一下收入院吧。”交班医生简单
: 的说道。
: 过几次院，好几封呼吸科医生有关治疗的信。
: 氧浓度下血氧勉强维持在90%，旁边陪着的是病人的女儿。
: 在家日常起居都很独立，今天据女儿说坐着好好的，突然一站起来就觉得呼吸困难，脸
: 色都变了，没有明显的胸痛，觉得可能是老病发作，就赶快来医院了。
: 意了。
|
|
|
n*******c
发帖数: 501 | 11 Haha...you should write the story about how you fight with ED physician.
It is always hard when the patient had a preexisting condition that may
potentially explain the symptom. It is even more difficult when the patient'
s renal function is not good that we have to justify giving her contrast and
putting her on risk of contrast induced nephropathy...
I was lucky that the patient has a good renal function and we don't lose
much by doing a CTPA.
effusion
between
【在 y******a 的大作中提到】
: Good catch. I had a similar case in my second year, an old pt presented
: with acute worsening of SOB and newly onset Afib, also has pleural effusion
: and recently diagnosed metastatic cancer. It was quite an argument between
: me and ER physician, and finally they agreed to do a CT angio before they
: signed out the patient to me. I was right, and the pt was taken by ICU in
: the end.
|
n*******c
发帖数: 501 | 12 See my post. I did not convince him just by luck :)
You were right that I did not take responsibility at that time and that is
the time you want to impress the senior...
course after your senior said yes it
【在 b***u 的大作中提到】
: right, shall call cardiology no matter what, that's a protocol/legal issue
: instead of pure medical issue, especially when you were just intern. Of course after your senior said yes it
: became his responsibility, you should thank him for that:-)
: Good catch indeed.
:
: anyway until PE is comfirmed. :)
|
s**********t
发帖数: 217 | 13 Good catch.
As you said the patient is hemodynamically stable. She did not need systemic
thrombolytic treatment for now. Even though, a bedside ECHO should be done.
She had new onset RBBB, and leaking troponin which showed that her right
heart was under a significant stress from her masssive/submassive PE. It is
a grey area, wether she should get systemic or cath directed thrombolytic
treatment if she have RV dilatation or hypokinetic movement. |
n*******c
发帖数: 501 | 14 I would start systemic anticoagulation therapy right after we confirm PE if she
is haemodynamically stable. If she is not haemodynamically stable I would
even start systemic anticoagulation therapy before CTPA (it is OK with NSTEMI
anyway). Either way I would not wait till cath directed thrombolytic is
arranged (I am not sure if it is available in our hospital in the middle of
night but I am sure it is not able to be arranged within an hour and I am
not comfortable to wait).
I would do an urgent ECHO if she had chest pain just to exclude dissection.
Otherwise it can wait till after systemic thrombolysis is commenced. |
s**********t
发帖数: 217 | 15 I am talking about systemic thromyolytic treatment, like tPA. Not systemic
anticoagulation therapy, like heparin or LMWH. |
n*******c
发帖数: 501 | 16 再补充几句，
现实生活不是Dr House,不可能强充好汉，该follow protocol的一定不能含糊，特别是
自己负责任的时候，：） |
R*******t
发帖数: 367 | 17 果然很有悬念，previous DVT,说不定她有chronic PE很久了。
现在不少地方做triple rule-out，PE and aortic dissection基本上可以用CT thorax
PE protocol来完成，64-slice的CT machine很快就扫完了，计算机控制造影剂，等
contrast在肺主动脉时迅速扫描，以求pulmonary arteries的最佳增强效果。对aorta
的增强不是最佳，但是绝大多数serves the purpose, no need to radiate the
patient again for aortic dissection protocol.
Coronary CTA, however, the technique is very different from PE or dissection
protocol. First the field of view is centered to the heart for best
resolution. Secondly, the image acquisition needs to be EKG-gated, otherwise
the motion artifact is gonna screw the whole exam (we can tell patients to
hold their breath during certain exams, but can't tell them to hold their
heartbeat, lol). Post imaging processing is also complicated than CT PE
protocol, which only involves in sagittal and coronal reconstruction.
Another thing is lots of patients need to be premeditated before the
coronary CTA with beta blockers and NG, to make sure the HR is below 60bpm.
造影剂来说，只要病人肾脏功能还好，一天有150ml contrast还是可以的。CTPA一般
80ml就可以，还有富裕做angiogram。
如果要combine exams，从造影角度来讲势必对每个exam的质量都有所牺牲，我们也不
愿意去读suboptimal的exams。也许将来的科技可以在保证质量的情况下合并，那我们
和病人一样高兴。不过现在，我还是会情愿去读dedicated coronary CTA，即使这样，
还有的时候觉得片子不理想呢。
【在 n*******c 的大作中提到】
: 不好意思，因为制造悬念需要，省略了部分情节。
: 问病史是关键，这个病人没有任何血管危险因素，从不吸烟，没有高血压、糖尿病、冠
: 心病病史，只有这个肺病，年轻时有一次postpartum DVT.
: 最近和人讨论，都说要合并CTCA和CTPA，的确见过几个病人两者都做，吃了不少射线和
: 造影剂的说，这个问题还请Rubyheart多多指教。
|
n*******c
发帖数: 501 | 18 got you. Sorry I was mistaken. corrected it now.
Thanks for your opinion. As far as I rememberSystemic thrombolysis for PE is
never performed in my hospital back then. This patient is an old patient
with advance pulmonary fibrosis and I guess the risk outweight the benefit.
【在 s**********t 的大作中提到】
: I am talking about systemic thromyolytic treatment, like tPA. Not systemic
: anticoagulation therapy, like heparin or LMWH.
|
R*******t
发帖数: 367 | 19 你很棒啊，估计令你的senior一下子对你刮目相看，崇敬之心如滔滔江水。。。。。：
D
【在 n*******c 的大作中提到】
: 再补充几句，
: 现实生活不是Dr House,不可能强充好汉，该follow protocol的一定不能含糊，特别是
: 自己负责任的时候，：）
|
n*******c
发帖数: 501 | 20 多谢，其实这样的时刻在我来说少之又少，所以那么一件小事记到现在。
要说我以前在放射科读片会上的糗事才多呢。
我觉得放射科医生个个都像现在的那个英剧新福尔摩斯，你说看片就看片吧，肿么看出
这么多俺们临床病史没问出的东东，叫俺们脸往哪儿搁:(
【在 R*******t 的大作中提到】
: 你很棒啊，估计令你的senior一下子对你刮目相看，崇敬之心如滔滔江水。。。。。：
: D
|
|
|
n*******c
发帖数: 501 | 21 学习了，多谢多谢。
见过几个病人从放射科门诊转过来说是refer CTCA结果做出个PE来的，呵呵。
thorax
aorta
dissection
otherwise
to
【在 R*******t 的大作中提到】
: 果然很有悬念，previous DVT,说不定她有chronic PE很久了。
: 现在不少地方做triple rule-out，PE and aortic dissection基本上可以用CT thorax
: PE protocol来完成，64-slice的CT machine很快就扫完了，计算机控制造影剂，等
: contrast在肺主动脉时迅速扫描，以求pulmonary arteries的最佳增强效果。对aorta
: 的增强不是最佳，但是绝大多数serves the purpose, no need to radiate the
: patient again for aortic dissection protocol.
: Coronary CTA, however, the technique is very different from PE or dissection
: protocol. First the field of view is centered to the heart for best
: resolution. Secondly, the image acquisition needs to be EKG-gated, otherwise
: the motion artifact is gonna screw the whole exam (we can tell patients to
|
R*******t
发帖数: 367 | 22 No worries, I am surprised to see how many patients can be unclear of their
med hx and forget what they had done to their own body! Some people thought
they still have their gallbladder, but clearly it was taken out , and some
people thought they had appendectomy in childhood and there is a big fat
inflamed appendix on CT... Lol
【在 n*******c 的大作中提到】
: 学习了，多谢多谢。
: 见过几个病人从放射科门诊转过来说是refer CTCA结果做出个PE来的，呵呵。
:
: thorax
: aorta
: dissection
: otherwise
: to
|
R*******t
发帖数: 367 | 23 I have seen a few incidental PEs on ct of abd/pel exams too, in the imaged
portion of lung base.
【在 n*******c 的大作中提到】
: 学习了，多谢多谢。
: 见过几个病人从放射科门诊转过来说是refer CTCA结果做出个PE来的，呵呵。
:
: thorax
: aorta
: dissection
: otherwise
: to
|
