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Fluids: the hypotensive hypoxic patient with bilateral crackles will not respond well to a fluid challenge, but give a cautious fluid bolus (250 mL) if hypotensive with a clear chest, even with a raised JVP. In the setting of an inferior myocardial infarction this could reflect right ventricular ischaemia and volume loading alone may improve the cardiac output. • Monitoring: haemodynamically unstable patients need close monitoring. Central venous pressure lines have a role, but be cautious with the readings, watch the trend and do not overinterpret.

Other tests depend on clinical suspicion. If PE is suspected, then CT pulmonary angiography is the investigation of choice in this context (when a ventilation– perfusion scan is not likely to be interpretable). If an infective cause is expected, then take blood and sputum (if available) cultures. Note that echocardiography is increasingly available as an emergency investigation and can be particularly helpful in assessing left ventricular function, but interpret it with caution in patients with tachyarrhythmias.

Occurred over a period of time. Has she had recent breathlessness or had to slow down? • Haemoptysis: the commonest differential diagnosis of pleurisy is musculoskeletal pain, and this does not cause haemoptysis. • Calf/leg swelling or pain: these would suggest deep venous thrombosis (DVT) and strongly support the diagnosis of PE in this clinical context. • Has the patient had a DVT or PE before? • Is there a major risk factor? Ask about recent immobility/major surgery/lower limb trauma or surgery, pregnancy/postpartum, any major medical illness, taking oral contraceptives (as in this case) and a family history of such illnesses.

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Acute medicine by Coll.

by Kenneth

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