安藤周記 | 451780
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emmm，看了赛马的介绍看了一个晚上，该写写题目了=。=
来看看第16题吧~
A 55-year-old woman comes to the emergency department because of new onset shortness of breath for the past 3 hours. She has a prior history of deep venous thrombosis and current breast cancer treated with surgery and daily radiation therapy. She says she has been coughing up bloody mucus for the past hour. Her temperature is 37.5°C (99.5°F), pulse is 110/min, respirations are 18/min, and blood pressure is 140/80 mm Hg. Chest X-ray shows no abnormalities and lacks evidence of infiltrate or pulmonary effusion. Trending troponin levels are negative. Which of the following is the most appropriate next step in management?
55岁女性，呼吸困难来的，前面有深静脉血栓的病史...等下！怎么和上面的这么像啊！不会又是PE吧...
看下后面的，emmm，乳腺癌，做完手术了，放疗的患者。还有点咯血！
不说了看到这我觉得90%还是PE，这个比上一个还典型，三联征都出来了
呼吸次数还好啦，体温也是好的，血压，按现在的标准那就是高的。拍了胸片没啥，上面也说过了胸片上只有2%的概率会显示出PE的征象。肌钙蛋白也是好的，和上面一样的，先排除下心脏致死性的疾病
问下一步该怎么样
上一题都讲过PE了，这次应该会对了吧？一个坑栽第二次就不大好看了
A. Administration of fresh frozen plasma
B. D-dimer blood test
C. Percutaneous coronary intervention
D. Rigid bronchoscopy（支气管镜）
E. Spiral computed tomography scan
不说了，CT增强！
我们下次看看解释吧~
A. Administration of fresh frozen plasma
Patients who are at risk for acute bleeding and are being treated with coumadin（香豆素） can be given fresh frozen plasma to reverse the effects of coumadin. Fresh frozen plasma achieves reversal faster than vitamin K.
Emmm,我前面看选项的时候也不知道输血浆干什么，从解释看起来是依据那口血来出的题目。也可能是不是以前发现了DVT或者是放疗的时候需要用到抗凝？
这边的解释是我们用血浆的话来对抗香豆素类的作用会比用VK快一点
B. D-dimer blood test
A D-dimer is a fibrin degradation product（纤维蛋白降解产物）. The test is very sensitive but not specific for a pulmonary embolism. Hence, a D-dimer blood test is preferred in cases where the likelihood of a pulmonary embolism is low.
DD嘛，敏感度很高特异性不高的东西，DD正常的话基本可以排除PE了。但是一般PE风险比较小的病人才测这个吧，这位三连都出来了，应该用特异性高的方法才对
C. Percutaneous coronary intervention
Percutaneous coronary intervention is an invasive procedure in which a catheter is inserted through the femoral artery and intravenous contrast is utilized to visualize the coronary vasculature. A drug-eluting stent（药物洗脱支架） can be placed to open the stenotic vessels. More serious cases of coronary disease can be treated with surgery.
冠脉介入就算了吧，这位不是心脏的问题
D. Rigid bronchoscopy
Rigid bronchoscopy is the preferred procedure for the removal of aspirated foreign objects and massive hemoptysis (>600 cm3 of blood loss through the pulmonary vasculature in the past 24 hours).
支气管镜是清除吸入的异物以及大咯血的首选方法，但是这位不是大咯血，所以pass
这边还贴心的用括号标出来了大咯血的诊断标准诶~
E. Spiral computed tomography scan（正解）
Main Explanation
This patient likely has a pulmonary embolism (PE) - the next step is to perform a spiral computed tomography (CT) scan. A PE is a life-threatening disease and should not be missed. Large PE (such as "saddle emboli” affecting both pulmonary arteries) can result in hemodynamic instability, acute onset right bundle branch block（右束支传导阻滞）, cardiac arrest, and death. PE，也是我们四大致死性胸痛之一，首先要排除的东西。这位患者高度怀疑，所以要赶紧做个CT看看。大的肺栓像那种马鞍状的栓子可以左右两边都堵了，那真的是......
However, some cases of PE can have subtle symptoms and thus require a high index of suspicion to diagnose. In situations where the diagnosis of PE is unclear, the Wells criteria can be utilized to guide diagnosis and treatment. A Wells score greater than 4.0 signifies that a pulmonary embolism is a likely diagnosis and should be followed up with a spiral CT scan. A Wells score less than or equal to 4.0 means that a PE is unlikely and should be followed up with a D-dimer blood test. Elevated D-dimer levels have a high sensitivity, but poor specificity, for pulmonary embolism.
但是，我觉得啊，容易判断的PE基本都上墙了，但是不容易诊断的呢？前面说过了用上次的那个wells评分。这边以4分为界，大于4分的去做CT，小于4分的测个DD In this clinical vignette, this patient has a Wells score of at least 5.0. Since she does not have any contraindications to intravenous contrast, the next appropriate step would be a spiral CT scan.
这个患者的评分嘛...超过5分了所以应该做CT，大家可以翻到上次的文章复习复习这个评分，看来还挺重要的
