Our Patient
40yo CM Presented to ED with c/o Acute SOB, Tachycardia and overall feeling that he was going to die.
Felt pain in his Right leg while walking approximately 30 Min. prior to arrival, followed by severe Dyspnea and Tachycardia.
Though, by the time he arrived to the ED, his symptoms had subsided except for mild tachycardia.
1st occurrence of anything of this nature happening.
Seizure Disorder
Migraines
Tobacco Addiction
Osteoarthritis
HLP
Hypogonadism
B/L Elective Knee Arthroscopy 2 weeks prior to presentation.
Nasal Surgery 1987.
Aspirin 325mg 1 PO Daily
Dilantin 100mg 5 PO Daily
Zocor 20mg 1 PO Daily
Smokes 1PPD x 15yrs.
Denied any EtoH use, though has 6 beers/day in past docs.
No Illicit drug Use.
Occupation - Plumber.
Recently Married, Desires to start a family.
No Family History of Any Clotting disorders, Heart disease, Cancers or Chromosomal Abnormality to his knowledge.
Triage VS: 97.6, 104, 148/90, 20
On evaluation in ED, pt. is in NAD, sitting upright, and conversant.
At time of our Eval. - VS: 97.6, 74, 126/83, 18, 93%RA
(Ht - 72.5”, 193lbs./ 87Kg, BMI - 26)
CVS: RRR, No M/R/G.
Lungs: CTA, no Increase Work of Breathing.
Extremities: 2+ pulses B/L, Warm, No C/C/E.
All else was also WNL.
Chemistry Panel:
Na-138, K+4.5, Cl-103,
BUN/Cr-15/.8, Gluc-147
CBC: WBC-8, H/H-13/39, Plt-248
D-Dimer: 1.16 (normal 0.42).
Coags: PT-12.3, PTT-26.9, INR-1.0
US LE- Negative for DVT.
CXR: Normal.
CTA Chest: Positive for B/L Pulmonary Emboli with R>L.
Upon assessment 3hrs later, still no increased working to breathe.
On Admission was Started on:
IVF, Loaded with 7000U Heparin IV, Started on Heparin Drip at 30cc/hr x12hrs., then Fragmin 18,000IU SC Daily on day 1.
Stayed the course, these 2 days in the hospital, remained stable.
Pt. was D/C’d home on Fragmin 18,000IU x7days and Coumadin 5mg QHS that was titrated up by his PCP.
Coag Panel with INR Q3days until therapeutic (2-3).
At D/C: INR- 1.0, was Therapeutic at 2.4 on 10mg Coumadin QHS one week later.
Hypercoagulability Panel on day 3 of Coumadin and Fragmin revealed:
Low Protein S at 59 (60-100 norm)
(done after the start of coumadin, which probably skewed results).
Prot C, Factor V leiden, Anti-lupus anticoagulant, Homocysteine level, Anti-cardiolipin Ab - ALL WNL.
Patient has returned to the ED 2 weeks after this admission for c/o a 15min. run of Tachycardia that had again completely subsided on admit. No Complaints of CP or SOB, pt. states that he is quite anxious now after B/L PE Dx.
An analysis of the regional distribution of Pulmonary Embolisms on CTA demonstrated that PEs occurred more frequently in the right lung, compared with the left, and more in the lung bases compared with the middle or upper zones. 