n*******c
发帖数: 501 | 1 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 g... 阅读全帖 |
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n*******c
发帖数: 501 | 2 （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！... 阅读全帖 |
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n*******c
发帖数: 501 | 5 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。 |
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n*******c
发帖数: 501 | 6 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 |
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n*******c
发帖数: 501 | 7 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... 阅读全帖 |
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R*******t
发帖数: 367 | 8 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... 阅读全帖 |
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