Case of the Week

Jake Darbhanga

— 3 min read
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Case of the Week
Photo by Nino Liverani / Unsplash

58-year-old woman presents to the emergency department with 4 days of worsening shortness of breath and a syncopal episode this morning when taking the trash out resulting in her hitting her head. States recently came back from France yesterday and felt as if she had a cold when she was on the way to France 7 days ago.

Her medical history is significant for hypertension, hyperlipidemia, history of aflutter requiring cardioversion years ago not on any current blood thinners.

Denies: chest pain, nausea, vomiting, leg pain, urinary changes, bowel changes, changes in appetite, headache, blurry vision, hearing changes

Initial Vital Signs

  • Temperature: 98.7°F (37.1°C)
  • Heart Rate: 101 beats/min
  • Blood Pressure: 102/68 mm Hg
  • Respiratory Rate: 28 breaths/min
  • Oxygen Saturation: 93% on room air

Physical Examination

The patient appears tired and has a abrasion to the right eyebrow without bleeding.

Cardiovascular examination reveals a regular rhythm with a RBBB.

Pulmonary examination demonstrates clear breath sounds bilaterally without wheezing or crackles.

Examination of the lower extremities reveals no unilateral leg swelling and negative Homans sign

Initial Differential Diagnosis

  • Pulmonary embolism
  • Acute coronary syndrome
  • Brain bleed
  • Fracture
  • Virus
  • Pneumonia
  • Pneumothorax
  • Acute heart failure

Emergency Department Workup

CBC, CMP, mag, PT/INR, PTT, BNP, Viral swabs, Troponin, ekg, CXR, CT Brain, c spine, face, CTA Chest

-we skipped the Dimer and went to CTA chest because he was already getting scanned for his fall and could not use PERC score because of age. His Wells score is 0 to 3 depending on how you fill it out, so mild to moderate risk. Did not use YEARS score because no d-dimer being used

Electrocardiogram

  • Sinus rhythm
  • Right bundle branch block
  • T-wave inversions in leads V1–V3

these findings increase suspicion for right heart strain.

Chest Radiograph

No focal infiltrate or pneumothorax is identified.

Laboratory Studies

  • CBC: Within normal limits
  • CMP: Unremarkable
  • High-sensitivity troponin: Mildly elevated at 810
  • BNP: Elevated at 350 although has had elevated bnp before at 200

Point-of-Care Ultrasound

Focused cardiac ultrasound demonstrates:

  • Right ventricular dilation
  • Septal flattening ("D-sign")
  • Mild McConnell sign

CT Pulmonary Angiography

CT angiography demonstrates moderate bilateral pulmonary embolisms involving the bilaterally with mild evidence of right ventricular strain.

remaining workup revealed no brain bleed or other findings althought THE PATIENT IS COVID POSITIVE as well

Emergency Department Management

The patient is placed on continuous cardiac monitoring and receives supplemental oxygen via nasal cannula, improving her oxygen saturation to 95%.

Two large-bore intravenous catheters are established.

Anticoagulation

Because there are no contraindications, intravenous unfractionated heparin is initiated.

Consultation

Interventional radiology is consulted

Given persistent tachycardia and significant right ventricular strain despite anticoagulation, catheter-directed thrombectomy is recommended.

Clinical Course

Mechanical thrombectomy is successfully performed.

Surprisingly no DVT noted on U/S inpatient

Following the procedure:

  • Heart rate decreases to 88 beats/min.
  • Oxygen requirement resolves.
  • Repeat echocardiography demonstrates improvement in right ventricular function.

The patient is transitioned to oral anticoagulation (Elliquis) prior to discharge and receives education regarding bleeding precautions and follow-up.

Teaching Points

  • Consider pulmonary embolism in any patient with unexplained dyspnea, pleuritic chest pain, tachycardia, or hypoxia.
  • A normal chest radiograph does not exclude pulmonary embolism.
  • Point-of-care ultrasound can rapidly identify right ventricular strain and deep venous thrombosis while definitive imaging is arranged.
  • Risk stratification determines treatment:
    • PESI SCORE IS COMMONLY USED
    • Low risk: Anticoagulation alone
    • Intermediate risk: Anticoagulation with close monitoring; consider catheter-directed therapy if clinical deterioration occurs
    • High risk (massive PE): Immediate systemic thrombolysis or thrombectomy if no contraindications
  • Early recognition and treatment significantly reduce morbidity and mortality.

Clinical Pearls

  • The combination of recent surgery, unilateral leg swelling, hypoxia, and tachycardia should immediately raise suspicion for pulmonary embolism. Recent travel is another thing to keep in mind and I have seen COVID patients with blood clots before.
  • Troponin and BNP elevations in PE indicate right ventricular strain and are associated with worse outcomes. PESI score can help stratify how bad a PE is and is good when talking to IR about it
    • Low risk PE doesn't always need to be heparinized and instead you can use Lovonox although keep in mind it is renal adjusted
  • Bedside ultrasound is an invaluable tool in unstable patients when CT imaging is delayed or not immediately available.
  • Sometimes you can use PERC criteria and Wells to determine whether to jump to CTA chest vs getting a D-Dimer. In pregnant patients YEARS criteria is helpful
  • Syncope personally alarms me for a PE if they have risk factors

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