Reviewer: S. Randhawa, M.D.
A 56-year-old Caucasian male (CM) came to the emergency room (ER) with a chief complaint (CC) of mid-sternal chest heaviness with shortness of breath (SOB) for two days.
Past medical history (PMH)
Ashen, ill-appearing male.
Chest: diminished breath sounds (B).
CVS: Tachycardic, clear S1S2.
Extremities: Peripheral varicose veins, 1+ edema (B). No Homan's sign or calf tenderness.
What is the most likely diagnosis?
Acute coronary syndrome (ACS)?
Pulmonary embolism (PE)?
What would you do? What happened?
He was given aspirin (ASA), nitroglycerin SL every 5 minutes x 3. His initial SpO2 was 89-90% on room air (RA) and he was put on 3 liters by nasal cannula (NC). Arterial blood gas analysis (ABG) was done.
ABG: pH 7.436, PaCO2 34, PaO2 90, SpO2 96% on 3 liters. His perioral cyanosis improved, and he felt better.
ABG shows respiratory alkalosis. He was hypoxic on RA (click to enlarge the images).
D-dimer was 5784.
CXR showed a shallow inspiration or low lung volumes. The lungs appeared clear.
With a positive D-dimer, initial presentation of hypoxemia, and HR 114 bpm, this patient was a "prime" candidate for a pulmonary embolus.
A spiral CT of the chest was ordered, and it came back positive for bilateral main pulmonary artery emboli.
What happened next?
He was started on a heparin bolus and drip, and admitted to ICU. Coumadin (warfarin) was started.
This is the initial CXR when the patient presented with PE. He was hypoxic and the spiral CT of the chest showed massive bilateral PE (click to enlarge the images).
CXR done 3 days later showed a wedge-shaped peripheral lesion, seen better on the follow-up CXR done 3 days after that (click to enlarge the images).
Third CXR, one week after the initial one. Close-up of the wedge-shaped peripheral lesion (click to enlarge the images).
The classic radiographic finding of pulmonary infarction is a wedge-shaped, pleural based triangular opacity with an apex pointing toward the hilus (Hampton hump). This is observed only infrequently.
Hampton hump (pulmonary infarction) in PE.
Pulmonary Embolus and Lung Infarction. FP Notebook.com.
Acute Pulmonary Embolism (Helical CT). eMedicine.
Oral rivaroxaban is non-inferior to standard therapy for symptomatic pulmonary embolism (PE) and DVT (NEJM, 2012).
Pulmonary Embolism Paths. A free Palm program, Palmdoc Chronicles, 2007.
Getting Lucky. The Happy Hospitalist, 01/2008.
A classic respiratory case. Life in the Fast Lane.
ABG data not useful in the assessment of suspected PE - Am J Resp Critical Care Medicine, 2000 http://goo.gl/cQAtg