What's Your Diagnosis? Pulmonary Embolism

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got the previous case on Diagnosing and Treating Pericarditis and Myocarditis in the Emergency Department correct.

Case Presentation: Evidence-Based Management of Pulmonary Embolism in the Emergency Department

An obese 55-year-old man reports exertional dyspnea that began 2 days prior…

The man says he is generally active, despite being obese, and says that he walks extensively for his job.
His ECG is normal sinus rhythm at 95 beats/min and his resting pulse oximetry is at 94%. There are no other abnormalities. Chest x-ray, natriuretic peptide, and high-sensitivity troponin are normal.
All of his symptoms can be explained by his weight, but you wonder whether you should start down a diagnostic pulmonary embolism algorithm…

Case Conclusion

Because all previous studies did not explain his dyspnea and mild tachycardia, you obtained a D-dimer, which returned at 1250 ng/mL. You obtained a chest CT angiogram that revealed the presence of a large pulmonary embolism. You began anticoagulation with LMWH. A Doppler study also revealed a DVT in his left leg, and an echocardiogram depicted right ventricular strain. His troponin I returned normal. You contacted your PERT team. This patient was intermediate-high risk, which now opened the debate for the best management. Ultimately, because of the patient’s size, it was determined that a catheter embolectomy was the best course. The procedure was performed, the patient did well, and was discharged to home.