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Query: UMLS:C0034065 (pulmonary embolism)
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The clinical and laboratory features in 62 patients with acute pulmonary embolism were analized. There were 26 males, and 36 females with mean age of 63 +/- 11 (range 37 to 90). The clinical symptoms include: dyspnea (92%), chest pain and/or chest tightness (65%), cough (50%), wheezing (29%), leg swelling (32%), hemoptysis (24%), syncope (18%), leg pain (10%). Clinical signs include: tachypnea (respiratory rate > or = 20 per minute) (79%), tachycardia (37%), deep vein thrombosis (29%), cyanosis (8%), fever (> 38.5 degrees C) (2%). The possible predisposing factors include: immobilization (18%), surgery (5%), deep vein thrombosis, ever(5%), malignancy (5%), pulmonary embolism, ever (3%). Arterial blood gas analysis (while patients breathed room air) revealed mean PH of 7.46 +/- 0.06, mean PO2 of 64.5 +/- 12.1 mmHg, mean PCO2 of 35.3 +/- 4.6 mmHg, mean Alveolar-arterial O2 difference of 36.5 +/- 16.6 mmHg. The electrocardiographic changes include; nonspecific ST-T change (61%), sinus tachycardia (20%), S1Q2T3 pattern (15%), atrial fibrillation (16%), incomplete right bundle branch block (10%), complete right bundle branch block (8%), atrial premature contraction (7%), paroxysmal supraventricular tachycardia (2%). The chest x-ray findings include: cardiomegaly (48%), regional hypovascularity (31%), atelectasis (5%), pleural effusion (5%), wedge-shaped infiltrate (3%), elevated diaphragm (6%). Venous plethysmography was performed in 49 of 62 patients. Of these 49 patients, 28 patients revealed positive finding. Of these 28 patients with positive finding, 18 patients had clinical evidence of deep venous thrombosis. The in-hospital mortality rate was 10% (6/62).
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PMID:[Pulmonary embolism: clinical and laboratory features in 62 patients]. 904 62

Venous thromboembolism shows a high incidence and a significant mortality. Even if valid methods are available, thromboembolism is underdiagnosed. There are a number of diagnostic difficulties. They concern the time of the diagnostic suspicion, the patient selection for the various procedures and their combination. These difficulties may be overcome by team work where specialists of different disciplines (surgeons, internists, experts in nuclear medicine, radiologists) integrate their competence to attain the established objectives. The integration results in "synergism", namely an added value greater than the sum of competences of the team components. Thus, an operational unit active 24 hours over 24 must be formed to diagnose and treat the largest number of cases of thromboembolism. To establish the clinical suspicion of thromboembolism is the first indispensable step for patient selection. Thromboembolism should be investigated in all patients with chest pain, dyspnea and tachypnea in the absence of preexisting cardiorespiratory disease. The team should evaluate the impact of signs and symptoms to establish a definitive clinical probability which can direct towards the suitable, least invasive imaging procedure. Perfusion scanning, when highly suggestive or normal, is conclusive. However in 70% of cases it is indeterminate. Thus it should be combined with other procedures and with the clinical assessment. In practice, many dubious cases remain unsolved. The team work represents an organizational response to this diagnostic and therapeutic inadequacy. The real change in strategy which has revolutionized the diagnosis of thromboembolism was the widespread use of color Doppler US in the diagnosis of deep vein thrombosis. Since pulmonary embolism as well as deep vein thrombosis are treated with the same therapy, it is adequate to document the thrombosis also in the absence of a definitive demonstration of embolism. The old-fashioned approach should be reversed and the investigation should be centered on the assessment of deep vein thrombosis: site, emboligenic potential, floating extremity and extension. The integration of the clinical assessment, scanning finding and color Doppler US lowers by about 20% the number of indeterminate cases and indicates the patients for whom pulmonary spiral CT or pulmonary angiography is required. In all patients with cardiorespiratory insufficiency still unsolved after the combination of noninvasive exams, pulmonary angiography or spiral CT is mandatory because of the high risk for death. The remaining ones can be followed with serial color Doppler US exams. The cost/benefit ratio shows that the noninvasive strategy is the least expensive, the least hazardous and the most effective. At present, effective therapies are available for thromboembolism. Standard heparin and low molecular weight heparin fractions, fibrinolytic agents, surgery and recently caval filters are playing a major role in secondary prophylaxis of pulmonary embolism. The therapeutic approach is conditioned by various factors: the features of thrombosis, the presence and entity of pulmonary embolism, the patient cardiorespiratory condition, possible contraindications for anticoagulant and fibrinolytic agents. The presence of such a number of variables makes the use of a therapeutic algorithm, difficult. In this phase, based on our experience we believe that the present solution lies in the activity of an operational team of experts who establish the treatment to be performed.
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PMID:Multidisciplinary approach to venous thromboembolism. 906 64

Most of the lower limb surgeries are done under spinal anesthesia. This 21 year-old male had undergone open reduction with interlocking nail for his right femoral fracture and was scheduled for removal of interlocking nail. Spinal anesthesia was performed and a sensory block up to T8 level was achieved. During removing of the nail, the patient complained of chest pain, dyspnea and headache. Consequently, tachycardia and hypotension were observed. Then he coughed up pink frothy sputum. Ephedrine 5 mg was given to raise his blood pressure. About 3 min later, he recovered from the hypotension. Arterial blood gas analysis showed hypoxemia and hypercapnia. After endotracheal intubation, he was sent to surgical intensive care unit. In surgical intensive care unit, fat globules in urine, anemia and thrombocytopenia were noted. Chest roentgenogram showed patchy pulmonary infiltrates in the left lower lobe. A pulmonary artery catheter was inserted for pulmonary measurement, which read pulmonary artery pressure 45/28 mmHg, wedge pressure 14 mmHg, and cardiac output was 5-34 L/min. Supportive treatment which included steroid therapy, and O2 therapy with positive end-expiratory pressure was initiated under the impression of pulmonary embolism. The course in surgical ICU was uneventful and he left there three days later and was discharged on the fifth hospitalization day.
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PMID:[Removal of femoral interlocking nail-induced pulmonary embolism under spinal anesthesia--a case report]. 908 55

Diagnosis of pleural effusion, suggested by chest pain or dyspnea, is assessed by physical examination, chest X-ray sometimes completed by other imaging techniques, and mainly by thoracentesis. Thoracentesis is mandatory for the diagnostic of pleural effusion as three diagnosis are associated with an emergency treatment: pulmonary embolism; hemothorax; empyema. If the fluid is a transudate, no further invasive studies are necessary. If the cause of pleural exsudat cannot be established by a careful history, physical examination and fluid analysis, generally closed pleural biopsy should be done, followed, in absence of an established diagnosis, by thoracoscopy. At this time, less than 10% of the cases remain without explanation, leading to a careful follow-up of patients since a carcinomatous lesion may develop in 1/3 of them.
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PMID:[Diagnosis of pleurisy]. 924 95

A case of successfully treated fungal tricuspid infective endocarditis with repeated pulmonary embolism is reported. A 60-year-old man had received along term intravenous hyperalimentation for the treatment of the complication after hepatopancreatoduodenectomy, associated with Candida sepsis. He was once discharged, successfully treated with antifungal agents. But he was readmitted to our hospital due to fever, cough and chest pain. Blood culture revealed Candida tropicalis. Pulmonary scintigraphy and angiography revealed multiple infarcts of the right lung, and echocardiography showed vegetation on the tricuspid valve. Because of exacerbation of shortness of breath, tricuspid valvuloplasty and thromboembolectomy in the pulmonary arteries was performed. Postoperative course was uneventful and he had a marked improvement of dyspnea after operation.
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PMID:[A case of successfully treated fungal tricuspid infective endocarditis with repeated pulmonary embolism]. 925 38

Chest pain is the initial symptom of many life-threatening disease processes. Pain may arise from any structure located in the thoracic cavity. Cardiac causes of chest pain usually have anginal symptoms. Noncardiac causes have a variety of chest pain characteristics. Diseases that require immediate attention and intervention are myocardial infarction/unstable angina, dissecting aortic aneurysm, pericarditis, pulmonary embolism, pneumothorax, pneumonia, and acute chest syndrome. In order to evaluate a patient with the complaint of chest pain, the advanced practice nurse must be familiar with the differential diagnosis approach to acute chest pain.
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PMID:Acute chest pain. 931 75

Twenty-one physicians examined records of 43 patients who had attended the hospital because of chest pain. Of these patients, 20 had had coronary heart disease (CHD), 15 had had nonspecific pain, and eight had had pulmonary embolism. The physicians indicated the probability of CHD in each case on the basis of 18 clinical findings, not including ECG, x-ray, or biochemical studies. The trial was repeated five years later, using the same records, by 16 of the same physicians. Diagnostic accuracy was evaluated by ROC curves, and the weight ascribed to each cue was inferred by multiple regression with estimated probability of CHD as the dependent variable. No significant change of areas under the ROC curves with increasing length of clinical experience was observed. Multiple regression was significant in 30 of 37 analyses. The distributions of most physicians' estimates of probabilities had similar shapes five years apart. It is concluded that "experience" does not have a clear role in diagnostic performance based on recorded data and that personal calibration and preferences in estimating probabilities often persist for years.
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PMID:The role of clinical "experience" in diagnostic performance. 956 49

The acute clinical evolution is presented of a patient with previous myocardial infarction who was admitted for dyspnea and chest pain. Acknowledging the possibility of a new ischemic event, confronted with aortic dissection or pulmonary embolism, the clinical investigation is described up to the scintigraphic diagnosis of pulmonary embolism. The clinical presentation, diagnostic investigation and therapeutic decisions are discussed, with emphasis on the usefulness of pulmonary scintigraphy.
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PMID:[Pulmonary embolism: a clinical case documented, in acute setting, using pulmonary scintigraphic perfusion]. 960 18

The pulmonary complications remain the prime cause of morbidity and mortality in sickle cell disease. The pathogenetic mechanisms consists both of an alteration of the rheological properties of the blood, the existence of a hypercoagulability state and above all specific interactions between the abnormal sickle cells and the vascular endothelium and a dysregulation of the vascular reactivity in which nitrous oxide intervenes. The acute chest syndrome (ACS) is characterised by chest pain with dyspnoea and recent radiological abnormalities and it is an acute lung complication whose problem is one of aetiology. The infectious pneumonias are rarely documented. On the other hand, alveolar hypoventilation linked to infarcts of the thoracic ribs, thoracoabdominal trauma, subdiaphragmatic pain, the administration of analgesics causing respiratory depression, obesity or sleep disturbance are frequent causes of ACS. Bronchoalveolar lavage has revealed a frequency of fat emboli following infarcts in the long bones. Pulmonary emboli is rarely a cause. Pulmonary thrombosis is a serious complication, the diagnosis is difficult and is seen in a predisposed clinical setting. The treatment of ACS rests on controlled hydration and antibiotic therapy, oxygen therapy and controlled analgesic therapy. The indications for blood transfusion and for exchange transfusion merits a better evaluation. In the long term patients with sickle cell disease present with a failure of normal thoracopulmonary growth with a restrictive ventilatory defect and progressive diminution in the transfer factor of carbon monoxide with age. A history of ACS favours chronic lung disease. Pulmonary arterial hypertension is less frequent.
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PMID:[The sickle cell anemia lung from childhood to adulthood]. 960 86

Pulmonary embolism is a serious and potentially life-threatening disease that requires early recognition and treatment. In three patients, two men aged 60 and 61 and a woman aged 76, prominent severe chest pain and electrocardiographic changes suggesting ischaemic heart disease, lack of response to treatment, marked dyspnoea and haemodynamic instability eventually led to the clinical suspicion and subsequent diagnosis of pulmonary embolism. Electrocardiographic changes are indicative of right-sided overload and sometimes of arterial hypoxaemia. Although ECG changes are very frequent in cases of pulmonary embolism, the abnormalities observed are mostly nonspecific ST-T segment changes.
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PMID:[Chest pain and electrocardiogram abnormalities: consider pulmonary embolism]. 962 93


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