Pulmonary Embolism

Patient presentation:
Patient E.C. is a 46 year old female.  She is post-op day 1 from a hernia repair with Strattice™ mesh placement.  E.C. is obese, and has a history of hyperlipidemia, asthma, and smoking ½ pack per day for 25 years.  Overnight she was on 2 L of oxygen delivery by nasal cannula.  Her O2 sat on pulse oximetry was consistently 95-98%.  At 0800 her vitals signs are: 98% on 2L NC, RR 18, HR 86, BP 142/76, T 37.0. At 10:30 this morning she gets out of bed for the first time and sits in the chair.  At 11:15 the nurse is called to the room by the tech because E.C.’s oxygen saturation is reading 84-86% on 2L NC.  After being helped back to bed E.C. requires 5L oxygen by NC to maintain an oxygen sat of 94%.  E.C. denies chest pain but is complaining of “tightness” in her chest and that breathing is “hard”, “like I just hiked up a mountain”.  E.C. has clear breath sounds bilaterally, but are diminished at the bases.  She is alert and oriented x3, her heart sounds regular, her abdomen is soft and appropriately tender.  Her vital signs are:  94% on 5L NC, RR 24, BP 145/86, HR 102, T 37.2.

Differential list:
pulmonary embolism, myocardial infarction, and atelectasis.

Diagnosis:
An EKG is done and shows normal sinus rhythm, a BMP, CBC, and cardiac enzymes are sent to the lab.  All values are within normal limits.  A chest x-ray is done and shows atelectasis bilaterally at the bases of E.C.’s lungs.  The resident on call this day chooses not to do a spiral chest CT to rule out PE and encourages aggressive pulmonary hygiene to clear mucus and other secretions from the airway.   After 2 hours the patient is maintaining 94% oxygen saturation on 3L NC.  As the day progresses E.C. wavers between needing 3-5L oxygen and continues to complain that her chest feels tight and she is having trouble “getting a good breath”.  Later in the evening the resident orders the spiral chest CT with IV contrast and it shows a PE.

Treatment:
The patient is started on Lovenox® injections twice daily.

Outcome:
E.C. went home on post-op day #4 and she will continue the Lovenox® injections for 4 months.  She also went home with supplemental oxygen as needed.