Shortness of breath By: Tina Tarazi

Patient is a 49 year old F with PMH of NSCLC s/p chemotherapy and radiation and right frontal lobe resection in 12/2013 who presents to the ED with SOB, LE pain/swelling and R arm pain Clinical History 2

VS: T 97.5, BP 157/80, P 75, RR 22 Sat 97%RA Constitutional: Oriented to person, place, and time. No distress. Lungs: Effort and breath sounds normal. No respiratory distress, wheezing or rales. CV: RRR and normal heart sounds. Exam reveals no gallop and no friction rub.No murmur heard. Abdominal: soft, no distention or tenderness MSK: Bilateral LE calf swelling and pain and RUE swelling and pain. No erythema noted. Normal ROM Physical Exam 3

Pulmonary Embolism Pneumothorax Complication of lobe removal New onset of lung malignancy Lung infection Heart failure Working Diagnosis 4

Options for Imaging 5

- CTA is highly sensitive and specific -Use of V/Q has considerably diminished with the widespread use of CTA. It is particularly useful in people who have an allergy to iodinated contrast, impaired renal function or in pregnancy -Chest radiograph is an important initial study in the evaluation of suspected PE and may reveal an alternate reason for acute symptoms -A normal chest radiograph does not exclude PE -Transthoracic echo (TTE) and transesophageal echo (TEE) studies useful in evaluating right ventricular morphology and function Rational for Chosen Imaging Modality 6

“Dichotomized Wells” Pretest Probability 7

Clinical: hypotension and/or tachycardia CTA: RV/LV dimension ratio >0.9 Echocardiogram: RV dysfunction Risk stratification for Pts with PE

Virchow’s Triad

Normal Pulmonary Artery On CT - Axial View

Normal Lung on CT - Coronal View

Pt was given Enoxaparin and Warfarin in the ED DVT Therapy: Heparin with Warfarin bridge, INR goal In setting of malignancy, long term anticoagulation with LMWH for 3-6 mo or until remission of cancer Other options: TPA, Thombectomy, IVC filter TEE Treatment 15