Virginia Research Day 2021

Saddle Pulmonary Embolus Michael Rinker, DO., Eric Taylor, DO Sovah Health Family Medicine Residency Program, Danville, VA

Abstract # RC-9

Pertinent Physical Exam: BP 151/89, HR 68, RR 17, Temp 98.3, SPO2 94%. Elderly male in NAD with trace non-pitting edema bilateral ankles. No calf tenderness. Negative Homan’s sign b/l.

Background : 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. Chief Complaint & History: An 88-year-old AA male presented to the emergency department after an episode of self-resolved chest pain, palpitations, and SOB. Symptoms began the day prior and occured at rest. No aggravating or alleviating factors. He had a similar episode approximately 1 week prior to presenting to the emergency department that was short lived and also resolved spontaneously. In the emergency department, he was found to have elevated troponin at 1.28 and EKG which showing NSR at rate of 68 without ectopy or ST changes. He was started on a heparin drip and admitted to the PCU to rule out ACS. Past Medical History: Significant for hypertension, hyperlipidemia, pituitary adenoma s/p resection, esophageal achalasia, and gout. Family History: Mother deceased from Heart Disease. Father deceased from unknown cause. Review of Systems: Positive for palpitations, CP, and SOB, all of which have resolved prior to presentation to the emergency room. Negative for: cough, fever, chills, weakness, blurred vision, nausea, vomiting, diarrhea, abdominal pain, dysuria, or headache. Social History: No tobacco, alcohol, or illicit drug use. He lives with wife and completes all of his own ADLs.

Discussion: 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 echocardiogram 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. The cause of his PE is unknown and further workup with hematology would be recommended. Unfortunately, we were unable to follow up with this patient as he was transferred to a tertiary care facility. Conclusion: PE can be life threatening and should be considered in any patient presenting with chest pain, shortness of breath, or hypoxia. This patient had an atypical presentation as his symptoms had resolved prior to presentation. Once PE have be diagnosed, treatment with anticoagulation should be started and the patient should be evaluated for signs of right heart strain. Laboratory: Pertinent labs included a D-dimer elevated at 15.69 and troponin elevated at 1.28 .

Hospital Course: Patient was started on heparin drip due to elevated troponin with concern for ACS and admitted. Once evaluated by cardiology, a CTA of the chest was ordered to rule out PE. CT returned positive for a saddle embolus without signs of right heart strain. Heparin drip was discontinued and Eliquis 10mg BID was started. Patient subsequently developed an acute GI bleed 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. Radiology : : 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. Echocardiogram showed EF >65% with normal right ventricular size and function but did show a grade 1 diastolic dysfunction.

References: Thompson, B.T., & Kabrhel, C. (2020). Overview of acute pulmonary embolism in adults. In J. Mandel, & G. Finlay (Ed.), UpToDate. Retrieved 10/25/2020, from https://www.uptodate.com/contents/overview-of-acute-pulmonary-embolism-in-adults#H86227218 SOVAH Health Danville. Electronic medical record and PACS.

45

2 0 2 1 R e s e a r c h R e c o g n i t i o n D a y