PREFERRED PRACTICE PATTERNS1
6A: Primary Prevention/Risk Reduction for Cardiovascular/Pulmonary Disorders
6B Impaired Aerobic Capacity/Endurance Associated with Deconditioning
6C: Impaired Ventilation, Respiration/Gas Exchange, and Aerobic Capacity/Endurance Associated with Airway Clearance Dysfunction
6F: Impaired Ventilation and Respiration/Gas Exchange Associated with Respiratory Failure
A 34-year-old man presents to the emergency department complaining of shortness of breath and chest pain that he describes as right sided and increased with deep breathing. He states it started suddenly when he woke up and started moving. He denies fever, chills, nausea, vomiting, or cough. He has a recent history of multiple gunshot wounds resulting in ongoing pain in his upper back and T-10 paraplegia. One week ago, he was discharged from the hospital to a rehabilitation facility. He is currently taking acetaminophen/hydrocodone and ibuprofen for his pain, which has increased with his physical therapy and occupational therapy. He is also taking hydrochlorothiazide and captopril for hypertension and fluoxetine for depression. He recently quit smoking tobacco since he was hospitalized and denies any alcohol or illicit drug use. On physical examination, he is an otherwise fit young man who appears slightly short of breath and uncomfortable. His heart rate is 101 beats per minute, his blood pressure is 110/78 mm Hg, and his respiratory rate is 26 breaths per minute. His pulse oximetry is 96% on 2 L of O2 by nasal canula. His lungs are clear to auscultation. There is mild swelling of his left calf. He has no sensation in his lower extremities. Laboratory studies reveal a white blood cell count (WBC) of 10,000/mm3. Hemoglobin, hematocrit, electrolytes, and renal function are all within normal limits. A 12-lead electrocardiogram (ECG) reveals a sinus rhythm at a rate of 103 beats per minute. His chest radiograph reveals minimal bibasilar atelectasis but no evidence of infiltrates or effusions.2
Chest computed tomography and echocardiographic findings in a 55-year-old man with submassive pulmonary embolism. A. Chest computed tomography scan demonstrating multiple segmental emboli, including a central embolus in main pulmonary artery and extending into right pulmonary artery (R-PA). B. Transthoracic apical four-chamber view with severe right ventricular (RV) dilatation. C. Transthoracic parasternal short-axis view showing flattening of interventricular septum (“D-shaped” left ventricle [LV], arrowheads). D. Transthoracic short-axis view demonstrating the central clot in the main and R-PAs. Ao, aorta; L-PA, left pulmonary artery; PA, pulmonary artery; RA, right atrium; R-PA, right pulmonary artery. (From Garg RK, Bednarz J, Spencer KT, Lang RM. Acute pulmonary embolism. Circulation. 2000;102:2441, with permission.)
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