History

CC:

“I couldn’t breathe last night so I came here, but now I feel so much better.” 

HPI:

Pt is a 50 year old male with PMHx of asthma who presented to the ED on 9/3 as a transfer from Syosset Hospital. Pt presented to the ED of Syosset hospital on 9/2 with complaints of diffuse chest tightness, with no radiation, and inability to take deep breaths. Pt says the symptoms began suddenly earlier in the day (around 3 PM), but seemed to worsen at around 10 PM when he laid down to go to sleep. He says that he attempted to relieve the symptoms with the use of his Trelegy inhaler (Fluticasone furoate, an ICS, Umeclidinium, an anticholinergic, Vilanterol, LABA) which provided no relief. Denies any exacerbating factors. Pt admits to having a sedentary desk job with baseline mild swelling of bilateral lower extremities. Denies any unusual swelling, pain, redness or erythema of his legs. Pt denied fever, chills, headache, weakness, blurry vision, fatigue, numbness, paresthesia, syncope, back pain, smoking, recent URI, recent travel, pmhx of DVT/PE and known family history of cardiac disease or coagulopathy.  

On CTPA done at Syosset Hospital, findings were significant for  extensive bilateral pulmonary emboli in the distal main pulmonary arteries with extension into the adjacent segmental and subsegmental superior, middle and inferior pulmonary arteries bilaterally. These findings were concerning for R heart strain. Pt was given aspirin, heparin bolus and started on a heparin drip and then transferred to NSUH for further care. Upon arrival to NSUH, pt stated that the chest pain and dyspnea has resolved. Heparin drip continued.

Pt was spoken to at bedside this morning when he restated that he no longer feels chest pain or dyspnea. Denies dizziness, headache, confusion, hematuria, bruising and nausea. Vital signs continue to stay within normal limits, even after 5 minutes of ambulation. 

Pmhx:

• Asthma x unknown years

Home medications:

• Trelegy Ellipta 100 mcg-62.5 mcg-25 mcg/inh inhalation powder 1 puff QD PRN asthma

Hospital medications:

• Heparin drip- 25,000 units in dextrose 5% 250 mL (24 mL/hr)
  • Target PTT= 58-99
• IV heparin push-
  • 5,000 units Q6H PRN PTT between 40-57
  • 10,000 units Q6H PRN PTT less than 40
• Aspirin 81 mg 1 tab PO QD

Surgical History:

• No past surgical history.

Allergies:

• No known drug/food/environmental allergies

Family History:

• Unknown
• No known family hx of HTN, cancer, DM, cardiovascular disease, hypercoagulable disorder

Social History:

• Smoking: Denies
• Alcohol: Denies
• Illicit drug use: Denies
• Marital History: Single
• Language: English
• Occupational History: Desk job for a bank
• Travel: No recent travel
• Home situation: Lives alone on long island
• Sleep: Endorses sleeping about 7-8 hours at night and feeling well rested
• Exercise: None
• Diet: Admits to diet with fast food, protein, fruits, vegetables and carbs
• Caffeine: Denies

ROS:

• General: Denies night sweats, weight loss/gain, fever, fatigue, chills and change in appetite.
• Skin, hair, nails: Denies discolorations, moles, rashes, changes in hair distribution or texture, pruritus.
• HEENT: Denies head trauma, vertigo, visual disturbances, ear pain, hearing loss, tinnitus, epistaxis, discharge, congestion, sore throat, bleeding gums.
• Neck: Denies localized swelling/lumps, stiffness/decreased ROM
• Pulmonary: Admits to dyspnea. Denies cough, wheezing, cyanosis, hemoptysis.
• Cardiovascular: Admits to chest pain and swelling of lower extremities. Denies palpitations.
• Gastrointestinal: Denies constipation, dysphagia, pyrosis, flatulence, eructation, rectal bleeding, hemorrhoids, blood in stool, abdominal pain, nausea, vomiting and diarrhea.
• Genitourinary: Denies urinary frequency, nocturia, dysuria, urgency, flank pain, oliguria, polyuria and incontinence.
• Musculoskeletal: Denies joint pain, joint swelling, back pain, muscle pain and arthritis.
• Nervous system: Denies seizures, headache, loss of consciousness, ataxia, loss of strength, change in cognition/mental status/memory.
• Peripheral vascular: Denies intermittent claudication, coldness or trophic changes, varicose veins, peripheral edema, or color changes.
• Hematologic: Denies anemia, easy bruising or bleeding, lymph node enlargement, history of DVT/PE.
• Endocrine: Denies diaphoresis, polyuria, polydipsia, polyphagia, heat or cold intolerance, goiter or hirsutism.
• Psychiatric: Denies feelings of helplessness, hopelessness, lack of interest in usual activities, or suicidal ideations, anxiety, obsessive/compulsive disorder, aditory/visual/tactile hallucinations or ever seeing a mental health professional.

Physical

General:

• Well developed, morbidly obese male in no apparent discomfort appears stated age of 50. Neatly groomed, in hospital gown, alert and oriented x3. Ambulates well without support. 

Vital Signs: 

• BP: 135/86 mm Hg
• R: 20/min, regular rate and rhythm, unlabored
• P: 89 beats per minute, regular rate, rhythm and amplitude 
• T: 98.6 degrees F (oral)
• O2 Sat : 98% room air
• Height: 74 inches Weight: 345 lbs BMI: 45.5

Skin & Head:

• Skin: Warm and moist, good turgor. Nonicteric, no lesions, scars, or tattoos noted.
• Nails: Capillary refill < 2 seconds.

Nose/Sinuses:

• Nose: Symmetrical. No discharge visualized. Nares patent bilaterally. Nasal mucosa is pink and well hydrated. Septum midline without lesions, deformities, injection, or perforation. No foreign bodies.

Neck/Trachea/Thyroid:

• Neck: Trachea midline. No masses, lesions, scars, pulsations. 

Thorax and Lungs:

• Chest: Symmetrical, no deformities, no trauma. Respirations unlabored/ no paradoxical respirations or use of accessory muscles noted. Non-tender to palpation throughout. 
• Lungs: Clear to auscultation and percussion bilaterally. No adventitious sounds.

Cardiac Exam:

• Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated. 

Abdominal Exam:

• Abdomen with rounded contour with no scars, striae or pulsations noted. Bowel sounds normoactive in all 4 quadrants with no aortic/renal/iliac or femoral bruits. Non-tender to palpation throughout, no guarding or rebound noted. 

Mental status exam: 

• Patient is well appearing, has good hygiene and is neatly groomed. Patient is alert and oriented to name, date, time and location. Speech and language ability intact, with normal quantity, fluency, and articulation. Patient denies changes to mood. Conversation progresses logically. Insight, judgment, cognition, memory and attention intact.

Peripheral Vascular System:

• Extremities are warm with mild swelling of bilateral lower extremities. No erythema, warmth or tenderness of lower extremities. No varicosities or stasis changes. Calves are supple and nontender. 

Musculoskeletal: 

• No erythema, warmth or crepitus noted. Non-tender to palpation. 

Differential diagnosis:

• PE/DVT
• Antiphospholipid syndrome
• Cancer
• Factor V Leiden 

Labs:

• aPTT
  • >200 (range 24.5-35.6 sec)
• PT
  • 13.9 (range 9.5-13 sec)
• INR
  • 1.33 (range 0.85-1.15; bet 2 and 3 for PE and DVT)
• Troponin T
  • 75 (range 0-51 ng/L)
  • Could be due to R ventricular strain
• BNP
  • 847 (range 0-300 pg/mL)
  • Could be due to myocardial stress and R ventricular strain
• T&S
  • A+
• CBC

• CMP

• VBG

Imaging:

• EKG
  • Normal sinus rhythm
• Chest x-ray
  • Clear lungs
• Duplex lower extremities
  • Acute, occlusive above the knee DVT affecting the right common femoral vein in the distal thigh and right popliteal vein. Below the knee the right posterior tibial peroneal trunk and gastrocnemius veins are thrombosed. NO DVTs in LLE

Assessment:

• 50 year old male with PMHx of asthma presented to ED as a transfer from another ED with diagnosed bilateral PE. Pt was started on heparin drip and aspirin in previous hospital. Upon arrival pt’s initial complaints of chest pain and dyspnea had resolved. Overnight pt continued to receive the heparin drip. Today, vitals remain within normal limits, even with ambulation. Exam shows a comfortable male in no acute distress with no abnormal findings. Labs are significant for elevated aPTT, and mild elevation in PT likely due to the heparin drip. Troponin and BNP are also elevated, likely due to the R ventricular strain caused by the PE. All other labs are not significantly high or low. Duplex of the lower extremities found multiple clots of the RLE and no clots in the LLE.  At this time, pt will be continued on heparin drip and workup for hypercoagulable state will be done. 

Diagnosis:

• PE
• DVT

Plan:

• PE
  • TTE pending
  • Continue heparin drip
    • 25,000 units in dextrose 5% 250 mL (24 mL/hr)
  • Cardiology consult
    • Thrombectomy vs. heparin drip based on TTE results
  • Pulm and heme consult
  • Antiphospholipid syndrome workup
    • APS is a clinical and laboratory autoimmune diagnosis characterized by lab evidence of antiphospholipid antibodies and related complications (venous thrombosis, arterial thrombosis, thrombocytopenia, pregnancy mortality). It can be primary or secondary to lupus.
  • Maintain SpO2 >92%
• DVT
  • Heparin drip
    • 25,000 units in dextrose 5% 250 mL (24 mL/hr)
• Asthma
  • Trelegy Ellipta inhaler PRN

Addendum:

• TTE
  • Left ventricular systolic function is hyperdynamic with an ejection fraction visually estimated at 70 to 75 %.
  •  Mildly enlarged right ventricular cavity size and normal right ventricular systolic function.
  • Simply, the left ventricle is working harder than usual, but both ventricles are functioning well overall, with the right ventricle being slightly enlarged.
  • Cardiology suggested continued heparin drip
• APS workup

• Heme/onc consult, follow up Factor V leiden and prothrombin gene mutation 

Patient education:

• Explanation of the condition- DVT is a clot in a deep vein most often in the leg and a PE is a clot that traveled to the lungs. Risk factors include sedentary lifestyle and obesity. Also educate regarding the signs and symptoms.
• Importance of oral anticoagulation (with rivaroxaban or apixaban) after discharge, making sure to explain the risk of bleeding.
• Lifestyle changes- weight loss, exercise, staying away from smoking and alcohol, use of compression stockings, staying hydrated
• Importance of followup with heme onc, cardio and pulm
• Ensure proper use of inhalers, and recognizing an asthma flare.