Question

Ms. X is an 87y/o Hispanic female who presented to the ED after experiencing an episode of syncope this AM. She was getting out of the bed and when she stood up felt some chest pressure and fainted. She landed on her bed and did not sustain any injuries. She has not had any prior syncopal episodes. She has chronic dizziness which has not changed and has not started any new medications. She denies nausea, vomiting, diarrhea, a history of aortic stenosis, DVT, or PE. Currently she is experiencing chest pain which is mild in severity, constant, dull and radiates to her back between her scapula. Her past medical history is positive for: Diastolic Heart failure, HTN, CAD, hypothyroidism, hyperlipidemia, and breast cancer for which she just completed chemotherapy. Prior surgeries include a hysterectomy and bilateral cataract removal. Physical exam Vitals: 36-3-74-16-163/74, O2 sat is 89% on room air. Normocephalic. Alert & Oriented x3. Well developed. Eyes: PERL. No nystagmus Neck: Supple, no cervical lymphadenopathy Cardiovascular: Normal Rate and rhythm. No murmur, gallops. 2+/4+ radial, brachial, dorsalis pedis pulses bilaterally. 3+ pitting edema of lower extremities. Pulmonary: mildly dyspneic, not using accessory muscles. Lungs are clear in all lung fields. Abdomen: Soft and nontender, active bowel sounds. No peritoneal signs. Skin: warm, dry and pale. EKG: no ST or T wave changes. QTc is normal. CXR: without any acute changes, CT of Head: Negative VQ scan: V/Q ratio is 1.3. Lab Sodium Potassium Creatinine BUN Troponin T | BNP WBC Hematocrit Hemoglobin MCV Platelets Calcium Magnesium Phosphorus Glucose Result 134 mEq/L 4.1 mEq/L 0.86 mg/dL 17 mg/dL < 0.01 ng/ml 100 pg/ml 5,000 35.6% 12 g/dL 89.3 fL 240,000 9.2 mg/dL 2.1 mg/dL 4.2 mg/dl 122 mg/dL

1. The clinical scenario is most consistent with which diagnosis? You may simply list your answer below using a bullet point format. This does not have to be in a complete sentence.
2. What data in the clinical scenario supports your diagnosis? Make sure to interpret the lab values. You may simply list your answers below using a bullet point format. This does not have to be in a complete sentence. Interpret the labs that you list as part of your answer by indicating normal, high or low.
3. What risk factor(s) led to this person’s diagnosis? You may simply list your answer below using a bullet point format. This does not have to be in a complete sentence.
4. Describe the key pathophysiologic concepts of the diagnosis in question 1. To answer this question completely, you must answer all of the sub-questions below using complete sentences. Each sub-question may be answered in 1-6 sentences.
5. 1. What is the most common etiology for the diagnosis you identified in question 1?
   2. Describe how this disorder causes hypoxia.
   3. Describe the pulmonary ventilation to perfusion balance (V/Q)? What is the normal range for the VQ ratio?
   4. What is a V/Q mismatch? What does a low V/Q ratio indicate? What does a high V/Q ratio indicate?
   5. What type of V/Q mismatch is this patient likely experiencing and why?
6. For what actual or potential complications related to the diagnosis in question 1 does she need to be monitored? You may simply list your answer(s) below using a bullet point format. This does not have to be in a complete sentence

Answer 1

ox ox tient was diagnosed with pulmonary embolism (PE) since pakiant had v/o dato sloo Chere it had 1:3), pt acceired chemo therapy for breast cancer which is a major risk for Pe patient had happer lipidemia CAD Coronary artery diseases, typothyroidiem, Hypertension are also secondary risks for pulmonary embolism o i lab 3.5-4.5 meallt Sodium Potassium Creatinine BUN Troponin-T BNP Result my of Normal 134 meallt Brolur mealt 4.1 meglit 0.86 uglal 0.6-1.2 mildl It malal 20. ol nglul 0-004 nglah <9125 mg/ml 100 pg/m) 5,000 34 -48% Normal Normal Normal 10.30 malal Normal 41000-10,000 cell) WBC Normal Normal Normal Normal Hematocrit Hemoglobin 12-16 old! So-96 fL 8 9.3ft MY

2140,000 1,5-2i Normal alcun Magnesium hosphorus Glucose norma A platelebs 1.5-4 lakh I Normal 9.2 migld) 8.5-10.5uald) | Normal 2.1 megld 4.2 migld) 205.4.8 maldl 122 mild) 140.000 mald! Etiology (causes of PE > chemotherapy for breast cancer » Hyperlipidemia Ev Norma Coronary artery disocue (CAD) > > Hysterectomy. Risk factors Hypothyroidism. e typertension typer lipidemia, Cancer ( breast cancer) heart attack / CADLAR los is & surgery Chysterectomy

Wa ratio: > Wstands into alveoli for ventilation cair you breathe in). The os goes & coa exists. O stands for "perfusion" (bloo- -flow) Evo means amount of air that reaches your alredli divided with blood flow amount in capillaries in lungs. > Normal vle is 0.8 . If monellest to it called mis match > 4/0 Mismatch can cause hyponemia. May also lead to respiratory failure measured by ventilation (perfusion sean. > 1/6 21 means perfusion more than ventilation. Usually seen in asthma, heparto pulmonary syndrome, bronchitis, pulmonary oedema > A high va raho decreases perfusion and renblation is better. Usually seen in pulmonary embolism

Pathophyciologrp of per rien fainos chemotherapy Hyperlipidemia Pulmonary embolism & Mary embolon CAD. t Hypothyroidism pulmonary vascular pressure Abnormal got enchange : vuo miomatch mainly seen in I Back flow to right side - f heart ↑ Right ventricular pressure Right sided heart failure → Congashive diastolic heart failure. I sv vo VBP > Hypoxia - Respiratory failure PE may lead to decompensated congestive heart failure Carcine arrest, pulmonary infarction, arrhythmias pulmonary arterial hypertension ,pulmonary effussion, chock, death, so she should be monitored with ejection fraction CVEF), pulmonary wedge pressure, Arterial blood gases, w/o ratio, O2 saturation devolen