פוסט זה זמין גם ב:
עברית
Clement D. Lee, M.D., Jeremiah Hinson, M.D., Ph.D., and Matthew Davenport, M.D. 
Case Vignette
A Man with a Suspected Pulmonary Embolism
Clement D. Lee, M.D.
A 65-year-old-man with type 2 diabetes, class II obesity (body-mass index [BMI, the weight in kilograms divided by the square of the height in meters] >35), coronary artery disease, and chronic kidney disease (estimated glomerular filtration rate [eGFR] of 28 ml per minute per 1.73 m2 of body-surface area) presents to the emergency department after sudden onset of dyspnea 6 hours earlier that was associated with chest discomfort and slight light-headedness. He has had no recent surgeries or long-distance travel, and he reports no hemoptysis or swelling in his legs or feet.
On physical examination, he is afebrile, with a heart rate of 109 beats per minute, blood pressure of 135/88 mm Hg, and respiratory rate of 22 breaths per minute. His oxygen saturation is 87% while he is breathing ambient air. He appears uncomfortable, but his condition does not appear to be critical. Cardiopulmonary examination is normal. An electrocardiogram shows sinus tachycardia with no ST-wave or T-wave changes. The d-dimer level is 724 ng per milliliter (reference range, <650, adjusted for age); high-sensitivity troponin I is undetectable. A pulmonary embolism is suspected.
You are the physician evaluating this patient in the emergency department. You would normally recommend computed tomography (CT), preferably with contrast material, to help determine whether a pulmonary embolism is present, but you must decide whether contrast-enhanced CT should be avoided in this patient who has stage 4 chronic kidney disease.
Treatment Options
Which one of the following approaches would you take? Base your choice on the literature, your own experience, published guidelines, and other information.
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Recommend performing contrast-enhanced CT.
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Recommend avoiding contrast-enhanced CT.
To aid in your decision making, we asked two experts in the field to summarize the evidence in favor of approaches assigned by the editors. Given your knowledge of the issue and the points made by the experts, which approach would you choose?
- Option 1: Recommend Performing Contrast-Enhanced CT
- Option 2: Recommend Avoiding Contrast-Enhanced CT
