Masquerading Dyspnea – A Hidden Pulmonary Embolism Leah Colucci, B.S., William Korey, M.D. and Jennifer S. Jackson, M.D., FACEP University of Miami Miller School of Medicine, Division of Emergency Medicine

WORKUP CLINICAL HISTORY CBC CLINICAL COURSE 15.2 Ur Legionella Neg 69 Year Old Female - Shortness of Breath / Chronic Cough 11.8 470 pneumophilia 46.4 EMERGENCY DEPARTMENT: • Onset : 45 min. of severe dyspnea Mycoplasma Neg • Clinical deterioration requiring orotracheal intubation 1 week shortness of breath BMP pneumoniae IgM 136 98 10 • Severe hypoxic respiratory failure EMS arrival 265 Antibody • Suctioned white froth sputum with pulse oximetry 3.9 24 0.77 Ur Streptococcus Neg improvement to 80% • Context: 4 days prior – pneumonia diagnosis pneumoniae Urgent care - “spot on lung” EKG: Sinus tachycardia • Received IV enoxaparin 1 mg/kg while in CT Started on Z- Pak and Augmentin • Symptoms: Mild thoracic back pain, cough, can’t catch INPATIENT: breath, nausea and vomiting • IV tPA given despite recent surgery IMAGING • Physicians discussed with family the risks • PMH: Hysterectomy for uterine cancer 3 weeks prior. Urgent Care Chest X-Ray ED Portable Chest X-Ray • Bilateral lower extremities negative for deep venous Hypertension. On Aspirin daily. (4 days prior) thrombosis

• Discharged – Hospital day #6 on rivaroxaban PHYSICAL EXAM • Overall: Ill appearing, in extremis, severely hypoxic, struggling to breath • Vitals: HR 123, BP 107/61, RR 21, POx 66% NRB DISCUSSION • HEENT: No sore throat

• Cardiac: Tachycardia, no murmurs d• Pulm: CTA bilateral Mild rhonchi LUL No crackles, no wheezing • LUL small patchy • LUL dense wedge-shaped Resonant to percussion infiltrate/mass, 2.5 cm infiltrate • “Hampton’s Hump” • GI: Soft, nontender, nondistended

• Ext: No peripheral edema, equal in size

• Skin: Well healing surgical hysterectomy incision

VIRCHOW’S TRIAD 3 categories that contribute to thrombosis ED CTA Chest • Extensive bilateral pulmonary embolism • Stasis of blood flow • Left sided pulmonary congestion and infarct • Postoperative bedrest • Dilation of right ventricle • Endothelial injury • Surgical tissue damage • Hypercoagulability 2 Months Later • Complete resolution • Uterine cancer