n*******c 发帖数: 501 | 1 声明:本文纯属虚构,亦非本人真实经历,甚至有可能为代笔(按方某人的逻辑),各
位切勿对号入座,以假当真。
“嘟嘟…嘟嘟”page响了,该死,又是夺魂追命call,一看号码,糟糕,是妇产科病房。
值班最怕妇产科病人call了,产后的也就算了,产前的个个症状都不简单,有点什么内
科问题检查不敢随便做,药也不好随便用,得非常小心才行。
果然,33周孕妇,突发尖锐剧烈胸痛10/10,已经用了很多止痛药,疼痛还是没有缓解
,所以才内科急会诊。
看了病人,果不其然,又是那种似是而非的情况,年轻健康女性,初孕33周,产前一切
检查都没什么问题,这次入院是有些RUQ痛,大概妇产科不放心怕有急腹症的情况留院
观察的。现在腹痛缓解了很多,入院血液检查也都一切正常,本来病人已经准备明天办
出院的,不曾想今天出现了胸痛。
检查病人,气促,双肺呼吸音略弱但无罗音或哮鸣音,心脏和腹部都大致正常。监控显
示血压正常和SaO299% on ambient air.心电图显示sinus tachycardia,其他正常。
“what are you gonna do?”妇产科的医生催促着…“CTG is fine at the moment
but we cannot wait like this for too long…”
稳住稳住,我一边在心里提醒自己,一边迅速的order了血液检查,CXR和leg Doppler
,又叫值班intern给他做了个ABG,心里开始迅速的思考。
虽然知道不应该,可是这时还是很不厚道的希望doppler是阳性,个中原因相信各位应
该了解…
越怕黑越见鬼,结果出来了:
CXR: hypoinflation but essentially normal
Trop was negative
ABG showed mildly increased A-a gradient
Leg Doppler showed no DVT.
下一步该怎么办呢,病人的胸痛还是没有缓解,丈夫焦急的望着妻子,另一边是妇产科
医生不耐烦的目光…
(码字好累啊,欲知后事如何,请听下回分解,欢迎发表高见预测故事结局,呵呵) |
R*******t 发帖数: 367 | |
A*******s 发帖数: 9638 | 3 我会查amylase/lipase。
ruby, 你肯定在等她order吧, CT还是CTA还是VQ-scan?lol |
d********y 发帖数: 616 | 4 我会order CTA,快一些,先排除PE和膈疝.栓子未必来源于下肢,可能来源于羊水。 |
R*******t 发帖数: 367 | 5 How about alk phos? I would also do an U/S of abdomen checking for acute
cholecystitis too.
If PE is still a clinical suspicion, CT of thorax PE protocol is preferred
over V/Q scan, since the nuclear tracer Tc-99m MAA is excreted to the
bladder and has more radiation to the fetus. But we need cover her tummy
with lead apron when performing the CT.
I have a question about D-dimer, I have seen people order that for PE, but
is it specific enough?
【在 A*******s 的大作中提到】![](/moin_static193/solenoid/img/up.png) : 我会查amylase/lipase。 : ruby, 你肯定在等她order吧, CT还是CTA还是VQ-scan?lol
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A*******s 发帖数: 9638 | 6 Thanks for the education.
alk phos is also non-specific. Regarding D-dimer, our cardiologist believes
it is a scam or conspiracy of radiologists and ER Docs. lol. Only 1% D-
dimer positive has a PE, but 99% negative gets CT anyway. No wonder
radiologists get a nice pay. :)
【在 R*******t 的大作中提到】![](/moin_static193/solenoid/img/up.png) : How about alk phos? I would also do an U/S of abdomen checking for acute : cholecystitis too. : If PE is still a clinical suspicion, CT of thorax PE protocol is preferred : over V/Q scan, since the nuclear tracer Tc-99m MAA is excreted to the : bladder and has more radiation to the fetus. But we need cover her tummy : with lead apron when performing the CT. : I have a question about D-dimer, I have seen people order that for PE, but : is it specific enough?
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R*******t 发帖数: 367 | 7 我也觉得 d-dimer挺怪的,以前值班时,看D-dimer positive的,急诊order CT r/o
PE, 结果 D-dimer negative的,也还order,硬是没摸出规律来。lol 后来就不看了。
believes
【在 A*******s 的大作中提到】![](/moin_static193/solenoid/img/up.png) : Thanks for the education. : alk phos is also non-specific. Regarding D-dimer, our cardiologist believes : it is a scam or conspiracy of radiologists and ER Docs. lol. Only 1% D- : dimer positive has a PE, but 99% negative gets CT anyway. No wonder : radiologists get a nice pay. :)
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s**********t 发帖数: 217 | 8 The D-dimer things depends on the method your lab use. It was useless back
to 5-8 years ago. Now I think, in the last 5 year, the labs use the new
method to detect D-dimer. If the D-dimer is negative, you can rule out PE 99
%. Alon with negative doppler, you can rule out PE 100%. in low and moderate
risk for PE patients.
【在 R*******t 的大作中提到】![](/moin_static193/solenoid/img/up.png) : 我也觉得 d-dimer挺怪的,以前值班时,看D-dimer positive的,急诊order CT r/o : PE, 结果 D-dimer negative的,也还order,硬是没摸出规律来。lol 后来就不看了。 : : believes
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A*******s 发帖数: 9638 | 9 How about positive? Automatically CT?
99
moderate
【在 s**********t 的大作中提到】![](/moin_static193/solenoid/img/up.png) : The D-dimer things depends on the method your lab use. It was useless back : to 5-8 years ago. Now I think, in the last 5 year, the labs use the new : method to detect D-dimer. If the D-dimer is negative, you can rule out PE 99 : %. Alon with negative doppler, you can rule out PE 100%. in low and moderate : risk for PE patients.
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n*******c 发帖数: 501 | 10 D-Dimer
这个问题争论已久,现实是诊断PE最主要还是靠临床先评估risk,如果临床上一点都不
支持PE,那就宁愿不做,因为你知道negative不会改变结局,positive你也不会因此CT
,反而费尽心机解释,不如不做。high risk的你知道即使negative你也不放心最终也
是要CT的那就不如不做。所以order之前一定要自己能说服自己这个病人postive我就
orderCTA而negative我就不做CTA才行。
上面这个病人我是order了的,主要是因为我太想给她一个机会不做CTA的...这个病人
risk 主要是pregnancy和immobile due to RUQ pain,像“林海雪原”大哥说的,如果
doppler negative且d-dimer negative,我不会那么着急order CTA,除非临床上又发
生了变化比如血氧掉了或haemodynamically unstable,不过那样的话可能查不查也不
重要了,床边超声木有dissection就直接上heparin了... |
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n*******c 发帖数: 501 | 11 糖姐姐啊,可惜我遇到的那个医生不像您这么善解人意啊...
【在 R*******t 的大作中提到】![](/moin_static193/solenoid/img/up.png) : How about alk phos? I would also do an U/S of abdomen checking for acute : cholecystitis too. : If PE is still a clinical suspicion, CT of thorax PE protocol is preferred : over V/Q scan, since the nuclear tracer Tc-99m MAA is excreted to the : bladder and has more radiation to the fetus. But we need cover her tummy : with lead apron when performing the CT. : I have a question about D-dimer, I have seen people order that for PE, but : is it specific enough?
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n*******c 发帖数: 501 | 12 今天比较忙,明天再续,诸位莫走开。
希望明天续的时候阅读人数能超过200...(真虚荣啊) |
d********y 发帖数: 616 | 13 这里面ABG A-a的差异是增加的呀。要么A增加要么a减低才有可能造成两者的差值增加。hypoinflation是不是可以除外A增加。那么就剩a了。
而a的减低就直指血液动力学的变化。这时候CTA是最有效,最省时间的方法啊。
欢迎拍砖,让我在挣扎中成长。
CT
【在 n*******c 的大作中提到】![](/moin_static193/solenoid/img/up.png) : D-Dimer : 这个问题争论已久,现实是诊断PE最主要还是靠临床先评估risk,如果临床上一点都不 : 支持PE,那就宁愿不做,因为你知道negative不会改变结局,positive你也不会因此CT : ,反而费尽心机解释,不如不做。high risk的你知道即使negative你也不放心最终也 : 是要CT的那就不如不做。所以order之前一定要自己能说服自己这个病人postive我就 : orderCTA而negative我就不做CTA才行。 : 上面这个病人我是order了的,主要是因为我太想给她一个机会不做CTA的...这个病人 : risk 主要是pregnancy和immobile due to RUQ pain,像“林海雪原”大哥说的,如果 : doppler negative且d-dimer negative,我不会那么着急order CTA,除非临床上又发 : 生了变化比如血氧掉了或haemodynamically unstable,不过那样的话可能查不查也不
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n*******c 发帖数: 501 | 14 All you said is very true. However things get complicated in pregnancy... |
s******v 发帖数: 477 | 15 My guess is hiatal herniation if the increased A-a gradient is negligible. |