Virginia Research Day 2021

Medical Resident Research Case Reports

09 Saddle Pulmonary Embolus

Michael Rinker, DO; Eric Taylor, DO Corresponding author: michael.rinker@lpnt.net

SOVAH Health Family Medicine Residency Program

Context: Pulmonary Embolus (PE) occurs when blood clots travel to the lungs and obstruct flow through the pulmonary arteries and if left untreated, can be life-threatening. Case Report: An 88-year-old AA male presented to ER after self-resolved chest pain, palpitations, and SOB. Found to have elevated troponin at 1.28 with a normal EKG. He was started on a heparin drip and admitted to the PCU to rule out ACS. A D-dimer was obtained after admission and returned elevated at 15.69. CTA of the chest revealed extensive saddle emboli extending into the bilateral pulmonary arteries. Past Medical & Surgical History: HTN, HLD, Gout. Social History: No tobacco, alcohol, or drug use. Lives with wife and completes all ADLs. Family History: Mother deceased from Heart Disease. Review of Systems: Positive for palpitations, CP, and SOB that have resolved prior to arrival.

Pertinent PE Findings: Elderly African American male in NAD, trace non-pitting edema bilateral ankles. No calf tenderness. Vital Signs: BP 151/89, HR 68, RR 17, Temp 98.3, SPO2 94%. Diagnostic Studies: CTA of the chest showed extensive saddle PE extending into the bilateral pulmonary arteries. Ultrasound of b/l LE showed nonocclusive thrombus involving the left superficial femoral and popliteal veins. D-dimer elevated at 15.69 and troponin 1.28. EKG showed NSR with rate of 70 without ectopy with no S1Q3T3. Echocardiogram showed EF >65% with normal right ventricular size and function but did show a grade 1 diastolic dysfunction. Treatment: Patient was started on heparin drip due to elevated troponin with concern for ACS. Once saddle pulmonary embolus diagnosed, heparin drip discontinued and Eliquis 10mg BID started. Patient subsequently developed an acute GI bleed once Eliquis was started and became hypotensive and

transferred to the ICU. Once in ICU, anticoagulation was discontinued, and patient was given 1-unit pRBCs and vascular surgery was consulted for IVC filter placement as well as gastroenterology for acute GI bleed. Initial Hgb 11 and dropped to 8. Diagnosis: Extensive saddle PE. Comments: PE are common condition and are responsible for approximately 100,000 deaths in the US each year. The most common presenting symptom is dyspnea followed by pleuritic chest pain. This patient had an atypical presentation for PE as he did not have persistent pleuritic pain, hypoxia, tachycardia, EKG changes, or echo with signs of right heart strain. PE can be treated with IV or PO anticoagulants and typically require 3-6 months of therapy. Extensive PE causing right heart strain or shock can be treated with embolectomy or tPA. Unable to follow up with patient as he was transferred to tertiary care center. The cause of his PE is unknown and further workup with hematology would be recommended.

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