Polmunary Embolism

1. Barbara Case

2. Content
● Background of the case
● Interview
● Medical History
● Possible Diagnose
● Test Ordered
● Final Diagnosis

3. Background
Barbara is 53 year old female visiting her
family. She completed a 19 hours trip. 2-3
hours before arriving at her destination she
noticed swelling in her legs and her right leg
started to hurt.
She experienced an asthma attack, her
breathing was laboured, she had wheezing,
after using her nebulizer her breathing was
regular but deeper than normal
She went to sleep, while sleeping the
husband woke up, her breathing was
laboured, she was wheezing and she
seemed anxious.
Barbara looked pale with pain in her chest
and neck radiating to her left arm
Her hand felt cold and sticky and her pulse
was racing
She mentioned that the pain gets worse
when she moves, after which she went to
the hospital, upon arrival she began to
cough blood

4. The Patient/Interview
Patient presented to the hospital with shortness of breath, chest pain in the last few
hours (painful pressure, weight on chest)
She was alert and oriented, sitting leaning forward, breathing through an open mouth and
gasping
An auscultation breath sounds are diminished across the whole chest, wheezing present
on both sides, regular HR 115 bpm, heart sounds are difficult to assess given the rapid
heart rate
Abdomen is not tender, not distended, no rebound, no hepatosplenomegaly, jugular veins
are filled
Swelling of both lower limbs is present, left ankle swollen
Right limb is much more intense, swelling reaches up to the knee, limb is red and warm
Remainder of skin is clear
Pulse present on dorsal artery of foot on both sides, no lymph nodes are enlarged.

5. Medical History
● She had 2 CC sections (aged 21, 31)
● 6mo ago she had a right hip replacement, no complications
● Asthma for 20 years, treated with glucocorticoids
● She has hypercholesterolemia
● Rheumatoid arthritis
● No cardiovascular events
● Stopped smoking 2 years ago, sporadic alcohol intake
● Her daddy died when he was 52 from MI
● No family history of thromboembolism
● Allergic to penicillin and cat fur
● Currently on hormone replacement therapy

6. Drugs
● Miflonide (Budesonide) - (400ug) 2 times a day
● Serevent (Samleterol) - (50ug) 2 times a day
● Ventolin (Salbutamol) - 2 doses in case of dyspnoea
● Activelle(hormone replacement terapy)- 1 pill1 time a day
● Atoris(Atorvastatin) 10 mg - 1 pill 1 time a day

7. Possible Diagnosis
● Myocardial infarction
● Angina
● Pulmonary Embolism
● Rupture of Aortic aneurysm
● Asthma attack
● Covid-19

8. Test Ordered
● Chest auscultation
● Cardiac enzymes
● Arterial blood gas
● CBC, electrolytes, creatine/BUN, Glucose
● INR/coagulation test
● Chest X-ray
● Ultrasound of Heart (Echogram) and Legs (Doppler)
● Coronary angiogram
● Angio CT
● EKG
● SARS-CoV2 PCR Test

9. Lab Results
● Blood pressure: 90/50 mmHg
● HR: 115/min
● O2 Saturaton: 88%
● RR: 22/min
● CBC: Normal
● SARS-CoV2 PCR: Negative
● Electrolytes and liver function Test: Normal
● Troponin T: Elevated 48 ng/l (first assessment) 49 ng/l (second assessment)
● D-dimers: 3357
● Arterial Blood Gases (ABG): Slightly elevated pH 7.48

10. Imaging Results
● EKG: RBBB (right bundle branch block) and features of overload of right ventricule
● ECHO: Dilated pulmonary trunk. Right ventricular cavity enlargement with free
wall hypokinesis
● Cest RTG: The presence of non-specific shadows and atelectasis in the left
pulmonary field. Right pulmonary field clear. No pleural effusion. Widened heart
silhouette. Normal diaphragm domes and both diaphragm-rib angles.
● Abdomen USG: Normal
● Ultrasonography of lower extremity veins: Thrombosis of the anterior and
posterior tibial veins in the right lower limb. Left limb without signs of thrombosis

11. Final Diagnosis
● Pulmonary Embolism due to deep vein thrombosis
● Likely Linked to hormonal replacement therapy and long car ride