Re: PE

1: Tachypnea (44/min) and Tachycarida without chest pain. Hypoxia. Lower temperature, haemodyanamically stable. ECG: AF, I did not see CXR. Any PE risk factors-Like previous DVT, recent surgery. He is a smoker, any hypercoagulapthy. ABG: I did not see Bicarbonate and BE. I guess the CO2 should be 24.9 instead of 249mmol/L. Otherwise it will be a respiratory acidosis, not a metabolic acidois. Which means you should not give bicarbonate. For sure, PE will be the first differential. Given haemodynamically stable, I don't consier thrombolysis or filter. I will give LWMH (Clexane 1mg/kg). Type 1 respiratory failure, consider intubation and ICU.

2. Cardiac workup: I don't think give frusemide and dexmeathasone will be a good idea. I also doubt the ENT diagnosis of laryngeal swelling. because you mentioned about no increased work of breathing, no accessory muscle use. I assume there was no stridor. Gas showed normal CO2, which was not consistent to the upper airway obstruction, otherwise CO2 will increase.

I will do a cardiac enzyme workup, Troponin I and CK, continue cardiac monitor, repeat Troonin 9 hours later.

3. Any possibility of DKA, GLU 18, metabolic acidosis, tachypnea (you said it was shallow breathing), any chance of (Kussmaul' breathing due to compensate the metabolic acidosis). By the way, I'd like to know the lactic acid and A-a gradient in the gas. A-a gradient is very useful for diagnose PE. I did not see urine or blood ketone. He might severely dehydrated due to DKA, therefore put him to AF, then PE. Or hypercoagulability of DKA put him to a hypercoagulabity, therefore, PE.

4. I will do two sets of blood cuture and urine culture to rule out septic sources.

5. Any chance of ARDS, could be secondary to shock.

6. I will do a portable X-ray ASAP, to rule to pneumothroax, because you metioned decrease breathing sound at left.

7. By the way, Dexmethasone won't change the symptom right away even it is a allergic larygngeal edema. As you know, from pharmacology, it will take 4 to 6 hours to work. Adrenaline nebuliser might be my first attemp and prepare for RSI intubation and ICU admission. Will you try normal intubation before tracheostomy. It is too aggrassive to me. For sure if you have a difficult intubation, I will do a tracheostomy after a fibrostiscop attemp.

8. Any AF patient should have a thyroid function test. It is a very basic workup for the cause of AF. He had hyperthyroidism. Any the clinical picture could be a hyperthyroidism crisis.

9: You can not use D-dimer for the dianosis of PE. But Di-dimer has a very good negative predictive value. We normally do a pretest risk assessment. If the risk is more than 2. I will straight forward to do a CTPA or VQ scan to rule out PE. There are some recent papers regarding PE diagonis and management.

10: Echocardiograme is required.

Did you follow up this patient. I'd like to know what was the final diagnosis.

Cheers

Dr L Bai