The Virtual Hospital: ElectricPE: The Diagnosis of Pulmonary Embolism: Diabetic with Fractured Ankle

ElectricPE: The Diagnosis of Pulmonary Embolism: Case Study 28

Diabetic with Fractured Ankle

Jeffrey R. Galvin, M.D. and James J. Choi, B.S.
Peer Review Status: Internally Reviewed

This case was a 70 year old female, type II diabetic who admitted to this hospital to help manage her blood sugar 6 days after she fell and broke her ankle. Her left leg was in a cast. She was noted to be tachypneic but aside from general malaise had no complaints referable to her chest. Her initial blood gases on room air were: PH 7.47 PCO2 35 and PO2 65 on room air.

The chest x-ray shows cardiomegally and a slightly elevated L hemidiaphragm.

She was referred to nuclear medicine to rule out pulmonary emboli because persistent tachypnea, in the face of a recent lower extremity fracture. A subsegmental area of decreased perfusion was present in the superior segment of the left lower lobe. The ventilation scan was unremarkable. The scan was read as intermediate probability for pulmonary embolus.

The first attempt to image the left lung was inconclusive. Therefore a balloon occlusion angiogram was done. The exam was read as positive for pulmonary emboli.

Case Assessment
This is a 70 year old female at high risk for deep venous thrombosis because of bed rest and a recent leg fracture. She presents with malaise.

In order for pulmonary angiography to be a reasonably sensitive test, the angiographer must be willing to obtain multiple views and magnified images. Balloon occlusion angiography may be necessary. (REFERENCE) Even with these measures it is important to recognize that the reliability of the test decreases for vessels that are smaller than segmental pulmonary arteries. (REFERENCE) In this particular case the current angiography staff at our institution could not identify a clot on the selective angiogram even though the study was previously read as positive.

1. Patients with pulmonary embolus may not have symptoms referable to the chest. While there is little that can be done for this group, it is important to be aware that we really do not know the prevalence of the disease in the population. (REFERENCE)

2. In order for pulmonary angiography to be a reasonably sensitive test, the angiographer must be willing to obtain multiple views and magnified images. Balloon occlusion angiography may be necessary. Even with these measures it is important to recognize that the reliability of the test decreases for vessels that are smaller than segmental pulmonary arteries.

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