Chief complaint: “I have severe pain and can’t catch my breath—I think I’m having a heart attack”

History of present illness: Mrs. VA is a 30-year-old women who presents to the hospital ER following 90min of chest pain. She describes the pain as an 8/10. An hour ago, she developed sharp and constant right sided chest pain and right sided mid back pain. The pain became worse when she attempted to lie down or take a deep breath and did not improve when she sat down. She is having difficulty breathing. She denies any fever, chills, or coughing up blood. She reports that she has just returned home 36 hours ago following a 13-hour flight from Tokyo.

Past medical history:

· Migraines with aura since age 23

· Mild endometriosis X 5 years

· Positive for Protein S deficiency

· One episode of DVT 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

Family history:

· Father has hypertension

· Mother died of metastatic cervical cancer at age 49

· Brother is alive an well

Social history:

· Lives with husband of 10 years and 8-year-old daughter

· Smoker X last 12 years, smokes ~ a pack a day

· Business executive with busy travel schedule

· Occasional caffeine use

· No alcohol or drugs


· Multivitamin once a day

· 30 mcg ethinyl estradiol w/ 0.3mg norgestrel daily X 4 years

· Cafergot 2 tabs at onset of migraine; with 1 tab every 30 minutes PRN

· Metoclopramide 10 mg PO HS

· Ibuprofen 200mg PO PRN for cramps

· Amitriptyline 50mg PO HS

Review of systems:

· No cough or hemoptysis

· No headache or blurred vision

· No auditory complaints

· No lightheadedness

· No extremity or neurological complaints

· All other systems are negative


· Demerol (nausea)

· Sulfa (pruritis)


The patient is a well-developed white woman who appears slightly anxious, but otherwise is in no apparent distress

Vital signs:

· BP 126/75

· P 105, regular

· RR 40, labored

· T 98.6

· Weight 136 lb

· Height 5’5”

· SpO2 99% in room air

Skin: Fair complexion, normal turgor, no lesions

HEENT: Pupils equal, round, and reactive, extra ocular eye muscles intact

Nose and throat clear, tympanic membranes clear

Mucous membranes pink and moist

Supple with no obvious nodes or bruits, normal thyroid, no jugular vein distention

Cardiac: Rapid but regular rate, no murmur, gallops, or rubs

Chest: Subnormal diaphragmatic excursion, no wheezing or crackles

Abdomen: Soft with + bowel sounds, non-tender and non-distended, no hepatomegaly or splenomegaly

Breasts: Normal with no lumps

Gen/Rectal: Heme negative stool

Extremities: Prominent saphenous vein in left leg with multiple varicosities visible bilaterally, peripheral pulses + 1 bilaterally, no cyanosis or clubbing, or edema

Strength throughout is equal, boot feet cool to the touch

Neurological: Alert and oriented X 3, cranial nerves II-XII intact, deep tendon patellar reflexes 2+

Lab results: 


ECHO: Ventricular wall movements within normal limits

V/Q Scan: Peripheral defect at right base. Some mismatch between perfusion abnormality and ventilation of the right lung, suggesting an intermediate probability for pulmonary embolus

Lower extremity venous duplex u/s: Both right and left extremities show abnormal of venous narrowing, prominent collateral vessels, and incompressibility of the deep venous system in the popliteal veins. These findings are consistent with bilateral DVT.

Pulmonary angiogram: Abrupt arterial cutoff in peripheral vessel in right base


1. What clinical manifestations, if any, suggest a pulmonary embolus in the is patient?

2. Identify five major risk factors for pulmonary thromboembolism.

3. Why do you think the patient is taking amitriptyline every evening?

4. Why is this patient taking metoclopramide every evening?

5. What condition does this patient have that is causing her to take ibuprofen for cramps?

6. Are any of the patient’s vital signs consistent with pulmonary thromboembolism?

7. Is this patient technically considered underweight, overweight, or obese or normal/ healthy? What is her BMI?

8. If you had noticed jugular vein distention what is a reasonable explanation?

9. Are any of the patient’s laboratory blood tests significantly abnormal? Provide a reasonable explanation for each abnormal test.

10. What might the patient’s chest x-ray show if it were taken now?

11. What does the EKG strip provided show?

12. Which single clinical finding provides the strongest evidence for pulmonary embolus in this patient?

13. Which is a more appropriate duration of treatment with warfarin in this patient: 3 months, 6 months, or long-term anticoagulation?

14. Is the use of a thrombolytic agent in this patient advisable?

15. Would you suspect that the is patient’s plasma D-dimer concentration is negative or elevated? Why?

16. Is massive pulmonary thromboembolism an appropriate diagnosis in this patient?

17. What is a likely cause of respiratory alkalosis in this patient?

18. Areas of ischemia in the lung from a pulmonary embolus usually become hemorrhagic. The patient’s chest x-ray is below, she presented with chest pain, hypoxia and lower limb DVT. Where is the hemorrhagic area? Upper right lung? Lower right lung? Upper left lung? Or lower left lung?

19. In terms of thrombus development, what is the fundamental difference between warfarin or alteplase?