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12 mmHg drop in blood pressure with inspiration
8%
11/142
Diffuse ST-elevation of all leads on electrocardiogram
0%
0/142
High levels of D-dimer
76%
108/142
Lucent gas space on chest radiograph
6%
8/142
ST-elevation of leads II, III, and aVF on electrocardiogram
4%
6/142
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This patient likely has pulmonary thromboembolism as demonstrated by her pleuritic chest pain, unilateral leg swelling, and tachypnea in the setting of long-standing immobility (e.g., long flight from Japan). Patients with PE will likely have elevated levels of D-dimer. Pulmonary thromboembolism (PE) refers to the obstruction of the pulmonary artery or 1 of its branches by a thrombus that originated elsewhere in the body. The risk of thrombus formation is increased by cancer, immobility, smoking, estrogen-based medication, pregnancy, obesity, and certain genetic conditions. Patients often present with tachypnea, tachycardia, acute chest pain, and sometimes a red, warm, swollen, and painful leg (as thrombus most commonly originates from the leg). Diagnosis is confirmed via a computed tomography angiogram but can be supported with high D-dimer levels. Treatment involves immediate anticoagulation with heparin. Figure A is a clinical image showing a unilaterally swollen and right, red leg. Incorrect Answers: Answer 1: 12 mmHg drop in blood pressure with inspiration describes pulsus paradoxus, a finding seen in cardiac tamponade, severe asthma, and COPD patients. Although cardiac tamponade can present with sudden chest pain, characteristic symptoms (e.g., low blood pressure, muffled heart sounds, and jugular venous distension) are not observed in this patient. Answer 2: Diffuse ST-elevation on all leads on the electrocardiogram is a finding suggestive of pericarditis, which presents with positional chest pain and can result from a URTI. However, this patient’s clinical history and leg presentation make PE more likely. Answer 4: Lucent gas space on chest radiograph describes findings seen in spontaneous pneumothorax, which is more commonly seen in thin, lanky young men. Answer 5: ST-elevation of leads II, III, and aVF on electrocardiogram describes a myocardial infarction, which is rarely seen in this patient’s demographic. Her clinical history and presentation make PE more likely. Bullet Summary: Pulmonary thromboembolism classically presents with acute pleuritic chest pain, tachypnea, and unilateral leg swelling.
4.7
(6)
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