Vinson David R, Isaacs Dayna J, Johnson Elizabeth J
The Permanente Medical Group, Oakland, CA, USA.
University of California, Davis, School of Medicine, Sacramento, CA, USA.
Eur Heart J Case Rep. 2020 Sep 7;4(5):1-4. doi: 10.1093/ehjcr/ytaa266. eCollection 2020 Oct.
For patients with acute pulmonary embolism (PE) diagnosed in the primary care setting, transfer to a higher level of care, like the emergency department, has long been the convention. Evidence is growing that outpatient management, that is, care without hospitalization, is safe, effective, and feasible for selected low-risk patients with acute PE. Whether outpatient care can be provided in the primary care setting has not been well-studied. We report a case of outpatient management of a low-risk patient with acute PE without emergency department transfer.
A 74-year-old woman with a history of recent surgery and immobilization presented to a primary care physician with 10 days of mild, non-exertional pleuritic chest pain. Her D-dimer concentration was elevated. Computed tomography pulmonary angiography identified a lobar embolus without right ventricular dysfunction. She declined emergency department transfer but was classified as low risk (class II) on the PE Severity Index and met the criteria of the European Society of Cardiology (ESC) for outpatient care. Her physician provided clinic-based PE management, discharging her to home with education, anticoagulation, and close follow-up. She completed her 3-month treatment course without complication.
This case describes patient-centred, comprehensive, outpatient PE management in the primary care setting for a woman meeting explicit ESC outpatient criteria. This case illustrates the elements of care that clinics can put in place to facilitate PE management without having to transfer eligible low-risk patients to a higher level of care.
对于在初级保健机构诊断出急性肺栓塞（PE）的患者，转诊至更高水平的医疗机构，如急诊科，长期以来一直是惯例。越来越多的证据表明，门诊管理，即不住院治疗，对于选定的低风险急性PE患者是安全、有效且可行的。在初级保健机构是否能够提供门诊护理尚未得到充分研究。我们报告一例低风险急性PE患者未转诊至急诊科而进行门诊管理的病例。
一名74岁女性，近期有手术和制动史，因轻度、非劳力性胸膜炎性胸痛10天就诊于一名初级保健医生。她的D - 二聚体浓度升高。计算机断层扫描肺动脉造影显示有一个叶段栓子，无右心室功能障碍。她拒绝转诊至急诊科，但根据PE严重程度指数被分类为低风险（II级），并符合欧洲心脏病学会（ESC）门诊护理标准。她的医生在诊所进行了PE管理，对其进行教育、抗凝并密切随访后将她送回家。她完成了3个月的治疗疗程，无并发症发生。
本病例描述了在初级保健机构对一名符合明确ESC门诊标准的女性进行以患者为中心的、全面的门诊PE管理。该病例说明了诊所可以实施的护理要素，以便在无需将符合条件的低风险患者转诊至更高水平医疗机构的情况下促进PE管理。
