REASON FOR CONSULTATION: Pulmonary embolism and chest pain.
HISTORY OF PRESENT ILLNESS: The patient is a (XX)-year-old female with past medical history of coronary artery disease and hypertension who developed sudden onset of chest pain while sitting and watching television. She denies shortness of breath, diaphoresis, nausea, vomiting, dizziness or lightheadedness. She was not doing anything and had left-sided chest pain that went down to her arm. This is different than before. She normally is a very anxious person and has been having chest pains for quite some time. Her daughter tells me that the last four days, she has been complaining of chest pains as well. Normally, she is not short of breath and is able to do everything without difficultly. She does not have a history of lung disease. She is a lifetime nonsmoker. About five years ago, she had an elective angiogram, which showed coronary disease and underwent bypass. Currently, she does have pain in the chest but is not short of breath at all. In the emergency department, a CT of the chest was done, which showed a small PE in the right upper lobe.
PAST MEDICAL HISTORY: Coronary disease and hypertension.
PAST SURGICAL HISTORY: CABG.
ALLERGIES: No known drug allergies.
CURRENT MEDICATIONS: Isosorbide, aspirin, felodipine, Diovan, pentoxifylline, Vytorin, and clonazepam for anxiety.
FAMILY HISTORY: The patient’s mother died of cancer. Her father has diabetes.
SOCIAL HISTORY: Lifetime nonsmoker. The patient did not have any exposure to chemical dust or fumes. Occasional alcohol use.
REVIEW OF SYSTEMS: Other than noted above, completely negative with regard to all systems. She does have chronic anxiety.
PHYSICAL EXAMINATION:
GENERAL: The patient is well appearing, in no apparent distress.
VITAL SIGNS: Temperature 98.2, pulse 76, respirations 20, and blood pressure 172/68. Currently, oxygen saturation in the emergency department is 99%.
HEENT: Eyes are anicteric bilaterally. Normocephalic and atraumatic. Oropharynx is clear without exudate or erythema.
NECK: Supple. No JVD.
CHEST: Clear to auscultation bilaterally.
CARDIOVASCULAR: Regular rate and rhythm. S1 and S2. Occasional systolic ejection murmur at the right upper sternal border, can hear it in the carotid on the right.
ABDOMEN: Soft, nontender, and nondistended.
EXTREMITIES: No clubbing, cyanosis or edema.
MUSCULOSKELETAL: There are some deformations of her DIP joints from arthritis.
SKIN: No rashes are noted.
LYMPH: No lymphadenopathy in the neck or supraclavicular area.
LABORATORY DATA: White count 7.8, hemoglobin 15.4, and platelet count 202,000. Sodium 134, potassium 4.7, chloride 100, bicarbonate 26, BUN 17, creatinine 0.8, glucose 170, calcium 9.1, and magnesium 2.1. AST 42, ALT 32, alkaline phosphatase 104, and total bilirubin 0.2. Troponin negative x2. Initial INR is 0.97. PTT is 26.6.
DIAGNOSTIC DATA: We reviewed the CT of the chest with contrast, which showed small right upper lobe pulmonary embolism. Chest x-ray was done, which was unchanged from the previous. D-dimer was elevated at 1020.
IMPRESSION: Pulmonary embolism.
RECOMMENDATIONS:
1. The patient was given Lovenox in the ER and was given Lovenox on the floor, but given her age and likely decreased creatinine clearance, we will switch her to IV unfractionated heparin tonight per protocol. Once the PTT is stable, we will start Coumadin to treat the target INR of 2.5 and range between 2 and 3. She needs to be on Coumadin for at least three to six months thereafter.
2. Studies have shown a very slight increased risk of underlying cancer when people develop pulmonary embolism from apparently unknown cause. She should, therefore, get age-appropriate cancer screening as appropriate.
3. We would like to get her an echocardiogram to evaluate the valves and systolic function and also to look at the right-sided function as well.
4. The patient is scheduled for a stress test in the morning to make sure that the chest pain is not from her heart.
5. We discussed this with the patient and her daughter at the bedside.
