MJ is a 35 year old female with PMHx HTN c/o of shortness of breath and chest pain x1 week. 

History elements

Symptoms started 5 days ago  

Sharp pain on right side of chest rated 7/10

Upon deep breathing the pain is worse 

Cannot walk more than a few steps which is not normal for her 

Chest pain associated with palpitations and diaphoresis 

Non radiating chest pain 

No alleviating factors 

Dry cough 

Admits to fatigue 

Hx of recent travel on 7 hour flight

Takes OCPs daily 

No fever, wheezing, coughing or blood 

No runny nose 

No sore throat 

No sick contacts recent but recent COVID infection 1.5 months ago

No history of COPD or asthma 

No prior similar chest pain 

Non smoker

No dizziness or lightheadedness  

Family history: mother MI at 50 years old 

Physical Exam:

Vital signs – Pulse: 112 Blood Pressure: 128/92 , RR: 20, O2 SAT 97% on RA

Gen – alert & oriented x 3, in NAD, well-groomed

HEENT – Head normocephalic, no visible trauma, no facial droop, no aphasia. PERRLA. Oropharynx well hydrated, uvula midline, mucosa pink. Thyroid normal. Neck supple, no bruits or JVD.

Skin –  warm, no erythema, rashes, scars, swelling or deformities noted, normal capillary refill throughout, sensation in tact throughout.

Chest –  Right chest wall tenderness. Symmetrical, no deformities, no trauma. Respirations unlabored/no paradoxical respirations or use of accessory muscles noted. 

Lungs – No consolidations to auscultation bilaterally. No adventitious sounds.

Heart: Carotid pulses are 2+ bilaterally without bruits. Regular rate and rhythm (RRR). S1 and S2 are distinct with no murmur. No friction rubs

Musculoskeletal: No soft tissue swelling/ erythema/ ecchymosis/ atrophy or deformities in bilateral upper and lower extremities. FROM (Full Range of Motion) of all upper and lower extremities bilaterally. 

Differential Diagnosis 

Pulmonary Embolism: patient with OCP use, recent history of travel, SOB and Chest pain 

Myocardial infarction: chest pain, SOB and family history but chest pain is non radiating, vitals within normal limits hence less likely 

Unstable angina: decreased tolerance to walking due to SOB and chest pain which is not baseline for her

Chest wall pain: reproducible chest pain 

Tests:

O2 SAT 97% on room air 

Cardiac Tele Monitor

ECG: Sinus Tachycardia at 105 BPM with low voltage. 

Cardiac Enzymes, blood gas, CMP, Coagulation studies, CBC: within normal limits 

CT Angio Chest PE Protocol w/ IV Cont Impression: Right lower lobe subsegmental pulmonary embolus.

No cholelithiasis. No acute intra-abdominal findings.

VA Duplex Lower Ext Vein Scan Bilateral Impression: Bilateral soleal vein thrombosis. Acute deep venous thrombosis: below the knee.

Transthoracic echocardiogram impression: Within normal limits. No right ventricular strain.

Diagnosis: Pulmonary Embolism and DVT  likely secondary to post COVD-19 infection, OCP use or recent travel

Treatment:

• Eliquis 10mg BID for 7 days and followed by 5mg BID for PE/DVT prophylaxis
• Tylenol PRN for pain 

Patient counseling

• Explain what a PE is and why blood clots are dangerous
• Explain how blood clots can be prevented – if on a long flight 
  • Stand up and walk around at least once every hour
  • Do not smoke just before your trip
  • Wear loose, comfortable clothes
  • Shift your position while seated, and move your legs and feet often
  • Wear knee-high compression stockings
• Discuss the possible side effects of Eliquis 
  • Risk of bleeding increases 
  • Signs of internal bleeding: severe headache, blood in urine, bloody or dark stool, vomiting blood, nosebleeds 
  • Anticoagulants may affects dental treatment 
• Patient vitals are stable, no right ventricular strain, stable for discharge but discuss if any complications arise to return to hospital