Unusual Presentation of Pulmonary Embolism

1. Emergency Department Case
Presentation 2
By
Dr Nagu Penakacherla MBBS,
MEd(USA), DNB (Family medicine)

2. • A 35 year old male presented to emergency
department with c/o of one episode of giddiness
associated with uprolling of eye balls and loss of
consciousness while having bath.
• Soon after the episode he had heaviness in the
chest.
• But no h/o of chest discomfort like this before no
h/o orthopnea or PND or fever. No h/o
hemoptysis/ DVT/Surgery/ Trauma / Prolonged
immobilization/travel

3. • Past history: H/o Diabetes Mellitus Type II , no
H/o Hypertension.
• Social history: No H/o smoking and Alcohol
• Family history: no relevant family history.
• Drug history: Metformin 500 mg BD

4. • Physical Examination:
• Vital Signs: – HR 90/min
– BP 140/90
– respiratory rate 22/min
– oxygen saturation via pulse oximetry 92% on
room air
– temperature 97.2° F (36.2 °C)

5. • HEENT: (Head, Eyes, Ear, Nose, Throat
examination) was normal.
• JVP was not raised.
• CVS – S1 S2 + No added sounds
• Chest –NVBS, clear no wheezes or crackles.
• Abdomen -soft non tender, no palpable liver,
spleen.
• Lower extremities: no edema, no other
abnormalities•

6. • Whats your Differential diagnosis ?
• What tests you want to perform Next???

7. • We have done ECG – Normal
• Chest X ray – Normal, No gross Abnormality.
• ABG- Normal PH-7.42 , PCo2- 33.2 , PO2-
85,Oxygen Saturation -92%.

9. • Determining the clinical probability of PE —
When PE is suspected, the modified Wells
criteria should be applied to determine if PE is
unlikely (score ≤4) or likely (score >4). The
modified Wells Criteria include the following:
• ●Clinical symptoms of DVT (3 points)
• ●Other diagnoses are less likely than PE (3 points)
• ●Heart rate >100 (1.5 points)
• ●Immobilization ≥3 days or surgery in previous
four weeks (1.5 points)
• ●Previous DVT/PE (1.5 points)
• ●Hemoptysis (1 point)
• ●Malignancy (1 point)

14. • Diagnosed as
Sub Massive Pulmonary embolism
• and treated with Inj Tenecteplase