Endgames Case report

A pain in the leg and breathlessness

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c925 (Published 11 March 2010) Cite this as: BMJ 2010;340:c925
  1. Harpreet Ranu, specialist respiratory registrar,
  2. Emma Holden, specialist respiratory registrar,
  3. Brendan Madden, professor of cardiothoracic medicine
  1. 1Department of Cardiothoracic Medicine, St George’s Hospital, London SW17 0QT
  1. Correspondence to: B P Madden Brendan.Madden{at}stgeorges.nhs.uk

    A 45 year old man with no previous medical problems was admitted to hospital with progressive breathlessness and discomfort in his left leg. He had no other symptoms and was not on any regular medications.

    On examination he was alert, with a pulse of 80 beats per minute, blood pressure 130/70 and respiratory rate of 20 breaths per minute. Peripheral oxygen saturations were 97% on room air. Heart sounds, jugular venous pressure, and respiratory examination were normal, but his left calf and thigh were markedly swollen and tender. He was initially treated with oxygen via a face mask and intravenous fluids.

    Doppler ultrasound of his left leg confirmed extensive thrombus extending into the common iliac vein. A later computed tomography pulmonary angiogram identified a large filling defect within the left main pulmonary artery.

    Questions

    1 What single blood test would be most useful to guide management in this patient?

    2 Which other non-invasive test would you request?

    3 What systemic treatment should this patient have?

    4 What are the long term complications of venous thromboembolism?

    Answers

    1 What single blood test would be most useful to guide management in this patient?

    Short answer

    A serum cardiac troponin level (I or T) will help identify whether this patient is at increased risk of clinical deterioration and help guide treatment of his large pulmonary embolism.

    Long answer

    From the information given, the patient has a large pulmonary embolus, but is haemodynamically stable without clinical evidence of right ventricular dysfunction secondary to his pulmonary embolus. Elevated cardiac troponins have a high sensitivity for myocardial injury.1 They are released as a result of right ventricular dilatation caused by a sudden rise in pulmonary artery and right ventricular pressures in patients with large pulmonary embolisms.2 Therefore, a raised cardiac troponin might indicate right ventricular microinfarction, dilatation, or both, and is a risk factor for early mortality after a pulmonary …

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