A 45-year-old male patient with a history of uric lithiasis and repeated expulsive nephritic colic for the past 25 years comes to the emergency room reporting palpitations and severe right lumbar pain for the past 2 hours. Urinalysis shows a pH of 5.5 and leukocyturia without proteinuria. The electrocardiogram confirms a previously unknown AF. Blood biochemistry shows a Creat of 0.9, Ca of 11 and LDH of 950. What is the most useful diagnostic maneuver to perform?
In principle, what you tell us does not fit with a nephritic colic. The urine is normal (without hematuria, caused by the lithiasis as it progresses), the Creat is normal (it can rise up to 1.9 in nephritic colic). The increase in LDH is non-specific and can be found in hepatic parenchymal lesions, AMI or pulmonary embolism, as well as in many other less frequent cases (tumors, myopathies, etc.). In this case, we have an important risk factor for embolism, which is atrial fibrillation, which, in addition, being a 45-year-old male, with no previous history, does not seem to respond to an underlying structural heart disease together with right lumbar pain, which could correspond to irritation of the pleura at the level of the right lumbar spine. Spiral CT with contrast has acquired great value in the diagnosis of PTE, due to its rapidity and good sensitivity, higher than 83-92% in most studies, and according to some it can reach 100% for central thrombi, located in main, lobar or segmental pulmonary arteries. Its specificity is greater than 90%. Nodes can produce false positives. It can also provide an alternative diagnosis in case PTE is not confirmed, so it would be a very useful test. Doppler ultrasound would be the most useful test to diagnose the source of the emboli, so it could also be a valid answer depending on what they mean by "useful". It is a noninvasive technique that has demonstrated its good sensitivity and specificity in the diagnosis of DVT compared to phlebography. It also allows the diagnosis of other pathologies that could justify the patient's symptoms. Its limitations are the assessment of infrapopliteal thrombi and, in many cases, in patients who are not thin, of the iliac and cava veins.
Plain abdominal x-ray.
Intravenous urography.
Spiral CT with contrast.
Abdominal ultrasound.
Doppler ultrasound.
Spiral CT with contrast has acquired great value in the diagnosis of PTE, due to its rapidity and good sensitivity, higher than 83-92% in most studies, and according to some it can reach 100% for central thrombi, located in main, lobar or segmental pulmonary arteries. Its specificity is greater than 90%.