Answers:
Answer 1
The patient had previous history of coronary artery diseases (CAD), hypertension, hypothyroidism, hyperlipidemia, undergone chemotherapy as well as hysterectomy. The patient suffered chest pain and felt pressure in the chest. Moreover, she also observed pain in the arms, shoulder, jaws, among others. She suffers from chronic dizziness, breathlessness, among others. However, other diagnoses can also be considered due to her medical history. The clinical scenario described here is most consistent with diagnosis of:
- Pulmonary embolism (Sharifi et al., 2013)
- cardiac syncope
- high blood pressure or hypertension syncope
- hyperlipidemia syncope
- Syncope can be due to toxicities following chemotherapy.
- Syncope can be associated with hysterectomy
- Hypothyroidism associated syncope
However, the most important and relevant diagnosis is pulmonary embolism as it is associated with chest pain, fainting, rapid breathing, pale skin, among others.
Answer 2
The data in the present clinical scenario that supports the diagnosis includes:
- mild or severe chest pain that radiates to the upper arm bone, shoulder bone and the collar (clavicle) bone (Than et al., 2014).
- Syncope can also be caused by severe dehydration as can be seen from her warm, pale and dry skin (Huang et al., 2015).
- She showed signs of breathlessness or dyspnea, which are presyncopal symptoms.
- Low sodium levels can also give rise to syncope, which can be observed in case of the patient.
- She also had a history of cardiovascular diseases that gave rise to pulmonary embolism.
Answer 3
The risk factors associated with pulmonary embolism includes:
- Cancer and its treatments (Sahut d’Izarn, 2012)
- History of cardiac diseases and heart attack
- Major surgeries like hysterectomy
- Blood vessel diseases like varicose veins, heart failure.
- Family history of pulmonary embolism
- Adenocarcinoma
- High D- dimer
- Low PaO2(Ma & Wen, 2017)
Answer 4
a. Etiology
Pulmonary embolism occurs as a result of a blood clot that gets stuck in the arteries of the lung. The blood clot usually arises from a deep vein present in the leg. This medical condition is called deep vein thrombosis (Goldhaber & Bounameaux, 2012). The blood clot becomes free, travel via the bloodstream and goes to the lungs. After entering the lungs, they block the arteries of the lungs. However, a fat droplet, amniotic fluid or air bubble can also cause pulmonary embolism. Various chemotherapy interventions for treatments of cancer can cause the formation of blood clots (Khorana et al., 2013). Heart failure can also give rise to pulmonary embolism. Other causes include thrombophilia (inherited tendency to develop venous thrombosis) and antiphospholipid syndrome (autoimmune disorder that results in arterial thrombosis).
b. Pulmonary embolism and hypoxia
The classic symptoms of pulmonary embolism is the onset of pleuritic chest pain, shortness of breath, and hypoxia. Hypoxia is the most common feature in association with pulmonary embolism. It occurs as a result of ventilation perfusion mismatch, lung atelectasis, loss of volume of lung, low saturation of venous oxygen, among others (Zondag et al., 2013).
c. Pulmonary ventilation to perfusion balance
The pulmonary ventilation to perfusion (V/Q) ratio can be defined as the ratio of the amount of air or oxygen entering the alveoli per minute to the amount of blood entering the alveoli per minute (Peinado et al., 2013). The V/Q balance is essential as it is one of the essential factors affecting the levels of oxygen in the alveoli. The normal range is 0.5-5. However, the average normal value is 0.8.
d. V/Q mismatch
V/Q mismatch results in increase or decrease in lung ventilation. Moreover, it can also be due to increase or decrease in lung perfusion. V/Q mismatch results in prevention of blood flow to capillaries and interference of oxygen supply to the alveoli (Le Roux et al., 2013).
Low V/Q ratios indicates that ventilation is not at par with perfusion. Alveolar oxygen decreases, results in low levels of arterial oxygen. This in turn results in high levels of alveolar carbon dioxide.
A high V/Q ratio mismatch indicates increased interference in the ability of oxygen to enter the alveoli.
e. V/Q mismatch
The patient is experiencing from high V/Q mismatch indicating that there are hindrances to the entry and supply of air or oxygen to the alveoli. This is because of the fact that the patient is suffering from breathlessness, dizziness, among others. Thus, pulmonary embolism is associated with high V/Q mismatch in the patient described here.
Answer 5
Complications associated with pulmonary embolism that require constant monitoring include:
- acute bleeding,
- pulmonary infarction,
- cardiac arrest,
- frequent venous thromboembolic events,
- chronic thromboembolic pulmonary hypertension (Klok et al., 2014)
- heparin related thrombocytopenia.
Reference List
Goldhaber, S. Z., & Bounameaux, H. (2012). Pulmonary embolism and deep vein thrombosis. The Lancet, 379(9828), 1835-1846.
Huang, J. J., Desai, C., Singh, N., Sharda, N., Fernandes, A., Riaz, I. B., & Alpert, J. S. (2015). Summer syncope syndrome redux. The American journal of medicine, 128(10), 1140-1143.
Khorana, A. A., Dalal, M., Lin, J., & Connolly, G. C. (2013). Incidence and predictors of venous thromboembolism (VTE) among ambulatory high?risk cancer patients undergoing chemotherapy in the United States. Cancer, 119(3), 648-655.
Klok, F. A., Van der Hulle, T., Den Exter, P. L., Lankeit, M., Huisman, M. V., & Konstantinides, S. (2014). The post-PE syndrome: a new concept for chronic complications of pulmonary embolism. Blood reviews, 28(6), 221-226.
Le Roux, P. Y., Robin, P., Delluc, A., Abgral, R., Le Duc-Pennec, A., Nowak, E., & Salaun, P. Y. (2013). V/Q SPECT interpretation for pulmonary embolism diagnosis: which criteria to use?. Journal of Nuclear Medicine, 54(7), 1077-1081.
Ma, L., & Wen, Z. (2017). Risk factors and prognosis of pulmonary embolism in patients with lung cancer. Medicine, 96(16)
Peinado, V. I., Gómez, F. P., Barberà, J. A., Roman, A., Montero, M. A., Ramírez, J., ... & Rodriguez-Roisin, R. (2013). Pulmonary vascular abnormalities in chronic obstructive pulmonary disease undergoing lung transplant. The Journal of Heart and Lung Transplantation, 32(12), 1262-1269.
Sahut d’Izarn, M., Caumont Prim, A., Planquette, B., Revel, M. P., Avillach, P., Chatellier, G., ... & Meyer, G. (2012). Risk factors and clinical outcome of unsuspected pulmonary embolism in cancer patients: a case?control study. Journal of Thrombosis and Haemostasis, 10(10), 2032-2038.
Sharifi, M., Bay, C., Skrocki, L., Rahimi, F., & Mehdipour, M. (2013). Moderate pulmonary embolism treated with thrombolysis (from the “MOPETT” Trial). The American journal of cardiology, 111(2), 273-277.
Than, M., Flaws, D., Sanders, S., Doust, J., Glasziou, P., Kline, J., ... & Frampton, C. (2014). Development and validation of the Emergency Department Assessment of Chest pain Score and 2 h accelerated diagnostic protocol. Emergency Medicine Australasia, 26(1), 34-44.
Zondag, W., Kooiman, J., Klok, F. A., Dekkers, O. M., & Huisman, M. V. (2013). Outpatient versus inpatient treatment in patients with pulmonary embolism: a meta-analysis. European Respiratory Journal, 42(1), 134-144.
