Posted: June 10th, 2021

Pulmonary Thromboembolism Case Study

A Case Study Analysis of Pulmonary Thromboembolism Risk Factors and Diagnosis

Abstract:
This paper presents an in-depth case study analysis of a 30-year-old female patient presenting to the emergency department with symptoms suggestive of pulmonary thromboembolism (PE). The patient’s clinical presentation, risk factors, diagnostic work-up, and treatment considerations are examined in detail. Literature on the epidemiology, pathophysiology, diagnosis and management of PE is reviewed to provide context and evidence-based analysis of the case. This study aims to elucidate the key factors in diagnosing PE and determining appropriate treatment for patients with this potentially life-threatening condition.

Introduction:
Pulmonary thromboembolism is a major cause of morbidity and mortality, with an estimated annual incidence of 60-70 cases per 100,000 in the general population (Essien, Rali and Mathai, 2019). PE occurs when a thrombus, usually originating from a deep vein thrombosis (DVT), embolizes and occludes the pulmonary arteries. Common signs and symptoms include dyspnea, pleuritic chest pain, cough, and hemoptysis. However, clinical presentation can be variable and nonspecific, making diagnosis challenging (Konstantinides et al., 2020). This paper analyzes the case of a young woman presenting with signs and symptoms concerning for PE, examining her risk factors and diagnostic evaluation to illustrate the clinical reasoning process.

Case Presentation:
A 30-year-old woman presented to the emergency department with sudden onset pleuritic chest pain and dyspnea that started 90 minutes prior to arrival. Her pain was sharp, constant, and localized to the right chest and mid-back. It was exacerbated by lying down and taking deep breaths. She had no fever, chills, or hemoptysis. Notably, she had returned from a 13-hour international flight 36 hours earlier.

Her past medical history was significant for migraines, endometriosis, Protein S deficiency, and a prior DVT treated with warfarin for one year. She had a 12 pack-year smoking history. Medications included oral contraceptives, amitriptyline, and ibuprofen as needed for menstrual cramps. Family history was negative for venous thromboembolism.

On exam, the patient appeared anxious but in no acute distress. Vital signs showed tachypnea with a respiratory rate of 40, tachycardia to 105 beats per minute, and normal oxygen saturation. Lung exam revealed decreased diaphragmatic excursion but no crackles or wheezes. Prominent varicose veins were noted in the lower extremities.

PE was suspected based on the patient’s abrupt onset pleuritic chest pain, dyspnea, and multiple risk factors including recent air travel, prior DVT, Protein S deficiency, oral contraceptive use, and smoking history. However, the differential diagnosis also included acute coronary syndrome, pneumonia, pneumothorax, and musculoskeletal pain.

Diagnostic testing showed sinus tachycardia on EKG and bilateral DVTs on lower extremity ultrasound. Chest x-ray was not reported. Ventilation-perfusion scan showed an intermediate probability of PE. Definitive diagnosis was made by CT pulmonary angiogram demonstrating an embolus in a peripheral right lung artery. D-dimer was presumed to be elevated given the documented PE, but not reported.

The patient was admitted and started on therapeutic anticoagulation. Thrombolytics were deferred as she was hemodynamically stable without evidence of right heart strain. Long-term anticoagulation was recommended given her multiple risk factors and recurrent VTE.

Discussion:
This case illustrates the importance of considering PE in patients presenting with pleuritic chest pain and dyspnea, especially in the context of VTE risk factors. The patient had numerous predisposing factors, including recent long-haul air travel, prior DVT, thrombophilia, combined oral contraceptive use, smoking, and varicose veins. Her initial presentation with sudden onset unilateral pleuritic pain and dyspnea was highly suggestive of PE as opposed to other cardiopulmonary conditions.

Clinical suspicion prompted a diagnostic work-up including EKG, chest imaging, and ultimately CT angiography which confirmed the diagnosis. Current guidelines recommend CT pulmonary angiography as the gold standard test for PE, with ventilation-perfusion scintigraphy as an alternative in patients with contraindications to CT (Konstantinides et al., 2020). Elevated D-dimer can also support the diagnosis but is nonspecific. Additionally, compression ultrasound of the legs should be performed to evaluate for DVT (Essien, Rali and Mathai, 2019).

Once PE is diagnosed, severity assessment drives management. Patients with hemodynamic instability, right ventricular dysfunction, or significant clot burden may benefit from thrombolysis or surgical thrombectomy in addition to anticoagulation (Essien, Rali and Mathai, 2019). However, for stable patients like the one in this case, anticoagulation alone is recommended. Choice of initial parenteral anticoagulation includes low-molecular-weight heparin, unfractionated heparin, or fondaparinux, with transition to an oral agent for long-term treatment (Konstantinides et al., 2020).

Duration of therapy depends on whether the PE was provoked or unprovoked, as well as patient risk factors. For this patient with a prior DVT and a known thrombophilia in addition to an incident provoking factor, current guidelines recommend indefinite anticoagulation to reduce risk of recurrence (Khan et al., 2019). However, bleeding risk must also be considered and weighed against risk of recurrent VTE when determining treatment duration.

Conclusion:
In conclusion, this case underscores the importance of maintaining a high index of suspicion for PE when evaluating patients with pleuritic chest pain, dyspnea, and VTE risk factors. Prompt diagnosis with CT angiography and initiation of anticoagulation is crucial to prevent morbidity and mortality. Treatment should be tailored to the individual patient based on clot burden, hemodynamic stability, risk of recurrence, and bleeding risk. Further research is needed to refine risk stratification tools and treatment algorithms for this complex and potentially fatal condition.

References:
Essien, E.O., Rali, P. and Mathai, S.C., 2019. Pulmonary embolism. Medical Clinics, 103(3), pp.549-564.

Khan, F., Rahman, A., Carrier, M., Kearon, C., Weitz, J.I., Schulman, S., Couturaud, F., Eichinger, S., Kyrle, P.A., Becattini, C. and Agnelli, G., 2019. Long term risk of symptomatic recurrent venous thromboembolism after discontinuation of anticoagulant treatment for first unprovoked venous thromboembolism event: systematic review and meta-analysis. BMJ, 366.

Konstantinides, S.V., Meyer, G., Becattini, C., Bueno, H., Geersing, G.J., Harjola, V.P., Huisman, M.V., Humbert, M., Jennings, C.S., Jiménez, D. and Kucher, N., 2020. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC). European heart journal, 41(4), pp.543-603.

Torbicki, A., 2020. Pulmonary thromboembolic disease. Clinical management of acute and chronic disease. Kardiologia Polska (Polish Heart Journal), 78(1), pp.47-64.

Wilbur, J. and Shian, B., 2021. Deep venous thrombosis and pulmonary embolism: current therapy. American family physician, 103(5), pp.295-301.

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Pulmonary Thromboembolism Case Study

PATIENT CASE
Patient’s Chief Complaints
“I have severe chest pain and I can’t seem to catch my breath. I think that I may be having a heart attack.”
History of Present Illness
Mrs. V.A. is a 30-year-old woman who presents to the hospital emergency room following 90 minutes of chest pain. She describes the severity of her pain as 8 on a scale of 10. An hourand-a-half ago, she developed sharp and constant right-sided chest pain and right-sided midback pain. The pain became worse when she attempted to lie down or take a deep breath and
improved a little when she sat down. She also has had difficulty breathing. She denies any fever, chills, or coughing up blood. She reports that she just returned home 36 hours ago following a 13-hour flight from Tokyo.
Patient Case Question 1. What clinical manifestations, if any, suggest a pulmonary embolus in this patient?
Past Medical History
• Migraines with aura since age 23
• Mild endometriosis
5 years
• Positive for Protein S deficiency
• One episode of deep vein thrombosis 2 years ago; treated with warfarin for 1 year
• Acute sinusitis 1 year ago
Past Surgical History
• Orthopedic surgery for leg trauma at age 7
• Ovarian cyst removed 10 months ago
CASE STUDY
9 PULMONARY THROMBOEMBOLISM
For the Disease Summary for this case study, see the CD-ROM.
Family History
• Father has hypertension
• Mother died from metastatic cervical cancer at age 49
• Brother is alive and well
• No family history of venous thromboembolic disease
Social History
• Patient lives with her husband and 8-year-old daughter
• Monogamous relationship with her husband of 10 years; sexually active
• 12 pack-year smoking history; currently smokes 1 pack per day
• Business executive with active travel schedule
• Negative for alcohol use or intravenous drug abuse
• Occasional caffeine intake
Medications
• 30 g ethinyl estradiol with 0.3 mg norgestrel
4 years
• Amitriptyline 50 mg po Q HS
• Cafergot 2 tablets po at onset of migraine, then 1 tablet po every 30 minutes PRN
• Metoclopramide 10 mg po PRN
• Ibuprofen 200 mg po PRN for cramps
• Multiple vitamin 1 tablet po QD
• Denies taking any herbal products
Patient Case Question 2. Identify five major risk factors of this patient for pulmonary
thromboembolism.
Patient Case Question 3. Why do you think this patient is taking amitriptyline at bedtime every evening?
Patient Case Question 4. Why is this patient taking metoclopramide as needed?
Patient Case Question 5. What condition is causing cramps in this patient for which she
requires ibuprofen?
Review of Systems
• (–) cough or hemoptysis
• (–) headache or blurred vision
• (–) auditory complaints
• (–) lightheadedness
• (–) extremity or neurologic complaints
• All other systems are negative
Allergies
• Demerol (“makes me goofy”)
• Sulfa-containing products (widespread measles-like, pruritic rash)
CARDIOVASCULAR DISORDERS
Patient Case Table 9.1 Vital Signs
BP 126/75 RR 40, labored WT 139 lb O2 SAT 99% on
room air
P 105, regular T 98.6°F HT 55
Physical Examination and Laboratory Tests
General
The patient is a well-developed white woman who appears slightly anxious, but otherwise is
in no apparent distress.
Vital Signs
See Patient Case Table 9.1
Patient Case Question 6. Are any of the patient’s vital signs consistent with pulmonary
thromboembolism?
Patient Case Question 7. Is this patient technically considered underweight, overweight,
or obese or is this patient’s weight considered normal and healthy?
Skin
• Fair complexion
• Normal turgor
• No obvious lesions
Head, Eyes, Ears, Nose, and Throat
• Pupils equal, round, and reactive to light and accommodation
• Extra-ocular muscles intact
• Fundi are benign
• Tympanic membranes clear throughout with no drainage
• Nose and throat clear
• Mucous membranes pink and moist
Neck
• Supple with no obvious nodes or carotid bruits
• Normal thyroid
• Negative for jugular vein distension
Patient Case Question 8. If the clinician had observed significant jugular vein distension,
what is a reasonable explanation?
Cardiovascular
• Rapid but regular rate
• No murmurs, gallops, or rubs
Chest/Lungs
• No tenderness
• Subnormal diaphragmatic excursion
• No wheezing or crackles

Abdomen
• Soft with positive bowel sounds
• Non-tender and non-distended
• No hepatomegaly or splenomegaly
Breasts
Normal with no lumps
Genit/Rect
• No masses or discharge
• Normal anal sphincter tone
• Heme-negative stool
Musculoskeletal/Extremities
• Prominent saphenous vein visible in left leg with multiple varicosities bilaterally
• Peripheral pulses 1 bilaterally
• No cyanosis, clubbing, or edema
• Strength 5/5 throughout
• Both feet cool to touch
Neurological
• Alert and oriented to self, time, and place
• Cranial nerves II–XII intact
• Deep tendon patellar reflexes 2
Laboratory Blood Test Results
See Patient Case Table 9.2
Patient Case Table 9.2 Laboratory Blood Test Results
Na 141 meq/L HCO3 27 meq/L Hb 11.9 g/dL WBC 5,300/mm3
K 4.3 meq/L BUN 17 mg/dL Hct 34.8% PTT 25.0 sec
Cl 110 meq/L Cr 1.1 mg/dL Plt 306,000/mm3 PT 14.0 sec
Patient Case Question 9. Are any of the patient’s laboratory blood tests significantly
abnormal? Provide a reasonable explanation for each abnormal test.
Patient Case Question 10. What might the patient’s chest x-ray reveal?
Electrocardiography
Sinus tachycardia
Echocardiography
Ventricular wall movements within normal limits
Lower Extremity Venous Duplex Ultrasonography
Both right and left lower extremities show abnormalities of venous narrowing, prominent
collateral vessels, and incompressibility of the deep venous system in the popliteal veins.
These findings are consistent with bilateral DVT.

38 PART 1 ■ CARDIOVASCULAR DISORDERS
V/Q Scan
Perfusion defect at right base. Some mismatch between perfusion abnormality and ventilation of right lung, suggesting an intermediate probability for pulmonary embolus.
Pulmonary Angiogram
Abrupt arterial cutoff in peripheral vessel in right base
Patient Case Question 11. Which single clinical finding provides the strongest evidence
for pulmonary embolus in this patient?
Patient Case Question 12. Which is a more appropriate duration of treatment with warfarin in this patient: 3 months, 6 months, or long-term anticoagulation?
Patient Case Question 13. Is the use of a thrombolytic agent in this patient advisable?
Patient Case Question 14. Would you suspect that this patient’s plasma D-dimer concentration is negative or elevated? Why?
Patient Case Question 15. Is massive pulmonary thromboembolism an appropriate diagnosis of this patient?
Patient Case Question 16. What is a likely cause of respiratory alkalosis in this patient?
Patient Case Question 17. Areas of ischemia in the lung from a pulmonary embolus usually
become hemorrhagic. The patient whose chest x-ray is shown in Patient Case Figure 9.1
presented with chest pain, hypoxia, and lower limb deep vein thrombosis. Where is the
hemorrhagic area—upper right lung, lower right lung, upper left lung, or lower left lung?
Patient Case Question 18. In terms of thrombus development, what is the fundamental
difference between heparin and alteplase?
PATIENT CASE FIGURE 9.1
Chest x-ray from patient who presented with chest pain, hypoxia, and lower limb
deep vein thrombosis. See Patient Case Question 17. (Reprinted with permission
from Kahn GP and JP Lynch. Pulmonary Disease Diagnosis and Therapy: A
Practical Approach. Philadelphia: Lippincott Williams & Wilkins, 1997.)

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