Pulmonary thromboembolism. A clinical case with misleading presentation




Sanchez, Christian
Adu Osayimwen, Ehiozogie
Madhrira, Machaiah


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Background Pulmonary embolism is a common and sometimes fatal disease. And despite its high incidence, the diagnosis continues to be very challenging and easily missed. Case Presentation We present a case of a 51 year old female with no past medical or surgical history who presented with complaints of shortness of breath and fatigue. Her only complaint was heavy menstrual flow lasting more than 7 days. On admission, physical exam was unremarkable. Vitals were stable. Patient was in no acute distress. Respiratory exam revealed clear lungs bilaterally. Examinations of her legs were normal. Negative Homans sign. GU exam showed patient was actively menstruating. Levels of serum electrolytes, glucose, BUN and creatinine were normal. CBC showed a hemoglobin of 6.7, hematocrit of 23.1 and MCV of 60.3. Platelet count was normal at 325. Iron studies obtained showed an iron level of 12, TIBC of 436, % saturation of 2.75 and ferritin level of 7. An ECG showed a regular sinus rhythm. Chest Xray was normal. Patient was diagnosed with Symptomatic anemia. Type and screen was ordered and patient was transfused with 2 units of PRBC. Wells score was calculated to be 0. However, PERC rule was applied, showed a score of 1 based on age > 50. Thereby necessitating further evaluation. A D-Dimer was obtained and found to be >5000. CTA showed an extensive bilateral lobar and segmental pulmonary thromboembolism, and possible right heart strain. The patient received standard anticoagulation treatment with unfractionated heparin. Conclusion Pulmonary embolism is a frequent cause of death in the United States. However, the clinical picture of pulmonary embolism is variable and most patients do not present with the classic triad of pleuritic chest pain, dyspnea, and hemoptysis. The Clinician should always remember to use the PERC rule in any patient that present with any one of these classic triad. And remember that a D-dimer level still remains very important to rule out PE.