Pharmacotherapy Case Study 12: Pulmonary Embolism (PE) By: Dr. Nehad Ahmed
Chief Complaint:
A 62-year-old male presents to the emergency
department with complaints of sudden onset shortness of breath, chest pain, and
lightheadedness. The patient states that the symptoms began abruptly 2 hours
ago while he was walking in his home. He describes the chest pain as sharp and
pleuritic in nature, worsened by deep breathing and coughing.
Subjective Data:
History of Present Illness (HPI):
The patient
reports experiencing sudden shortness of breath, sharp chest pain, and a
sensation of lightheadedness that started abruptly 2 hours ago while walking in
his living room. The pain is localized to the right side of his chest, is
worsened by deep breaths, and he rates the pain 7/10. He has had mild cough but
denies any hemoptysis. He denies recent trauma, fever, or upper respiratory
symptoms. The patient is anxious about his breathing difficulty and is
concerned about his symptoms.
Past Medical History (PMH):
Hypertension (diagnosed 15 years ago)
Chronic obstructive pulmonary disease (COPD)
(diagnosed 10 years ago)
Obesity (BMI 32 kg/m²)
History of deep vein thrombosis (DVT) in the
left leg 5 years ago, treated with anticoagulation therapy
No previous history of pulmonary embolism.
Medications:
Lisinopril 20 mg daily for hypertension
Albuterol inhaler as needed for COPD
Aspirin 81 mg daily
No current anticoagulation therapy since the
DVT was treated 5 years ago.
Allergies:
No known drug allergies.
Family History:
Father had a history of myocardial infarction
at age 60.
Mother has hypertension and diabetes.
Social History:
Smoking: Former smoker (1 pack/day for 20
years, quit 3 years ago).
Alcohol: Occasionally drinks, 2-3 drinks per
week.
Occupation: Office worker, sedentary lifestyle.
Physical activity: Inactive, has not engaged in
regular exercise recently.
Diet: High in fat and salt, low in fruits and
vegetables.
Review of Systems:
Cardiovascular: Denies palpitations or
dizziness.
Respiratory: Reports shortness of breath and
chest pain, no cough with blood, or wheezing.
Gastrointestinal: No nausea, vomiting, or
abdominal pain.
Neurological: No dizziness, confusion, or
weakness.
Musculoskeletal: No musculoskeletal pain or
swelling.
Objective Data:
Vital Signs upon Arrival:
Blood Pressure: 128/76 mmHg
Heart Rate: 110 bpm (tachycardia)
Respiratory Rate: 24 breaths/min (tachypnea)
Temperature: 37.2°C (99°F)
Oxygen Saturation: 90% on room air
Weight: 105 kg (BMI 32 kg/m²)
Height: 170 cm
Physical Exam:
General: Patient is anxious, slightly pale, and
in moderate distress due to shortness of breath and chest pain.
Cardiovascular:
Tachycardic with regular rhythm (sinus
tachycardia).
No jugular venous distention (JVD), no
peripheral edema.
No murmurs, gallops, or friction rubs heard on
auscultation.
Respiratory:
Tachypneic, shallow breathing with decreased
breath sounds on the right side.
Crackles noted in the right lower lung field.
No wheezing or rhonchi.
Abdomen: Soft, non-tender, no hepatomegaly or
ascites.
Extremities: No signs of DVT (no swelling,
redness, or tenderness noted in the legs).
Neurological:
Alert and oriented to time, place, and person.
No focal neurological deficits.
Laboratory Results:
Electrolytes: Sodium 139 mEq/L, Potassium 3.9
mEq/L, Chloride 101 mEq/L
Creatinine: 1.1 mg/dL (normal renal function)
Blood Glucose: 118 mg/dL (within normal limits)
Complete Blood Count (CBC): Normal white blood
cell count, hemoglobin 13.5 g/dL, hematocrit 41%.
D-dimer: 6.2 µg/mL (significantly elevated,
indicative of clot formation)
Coagulation Profile:
INR: 1.0 (on aspirin therapy)
Lipid Profile:
Total Cholesterol: 220 mg/dL
LDL: 150 mg/dL
HDL: 42 mg/dL
Triglycerides: 180 mg/dL
Chest X-ray:
Bilateral lung fields clear, no signs of
pneumonia or congestive heart failure.
Some minor atelectasis in the right lower lung
field, no obvious masses.
ECG (Electrocardiogram):
Sinus tachycardia at 110 bpm.
No significant ST-T changes or signs of
ischemia.
No atrial fibrillation or other arrhythmias.
CT Pulmonary Angiogram (CTPA):
Positive for pulmonary embolism (PE) in the
right pulmonary artery with partial occlusion.
Right ventricular strain noted on imaging with
right heart enlargement and moderate pulmonary hypertension.
Assessment:
The patient is diagnosed with acute pulmonary
embolism (PE), likely originating from a deep vein thrombosis (DVT). This is
supported by the clinical presentation, including sudden onset shortness of
breath, pleuritic chest pain, tachypnea, and tachycardia. The elevated D-dimer
further supports the diagnosis, and the CT pulmonary angiogram confirms the
presence of a right-sided pulmonary embolism with partial occlusion of the
right pulmonary artery.
The patient’s history of DVT, obesity, and
recent sedentary lifestyle contribute to the risk of developing PE. His COPD
may exacerbate respiratory symptoms, but it does not explain the acute onset of
chest pain and shortness of breath. The absence of recent immobilization or
surgery, however, makes his history of DVT more concerning in relation to the
current event.
Plan:
Immediate Management:
Anticoagulation therapy: Initiate
unfractionated heparin (UFH) or low molecular weight heparin (LMWH) for
immediate anticoagulation. Heparin drip should be initiated with a target aPTT
of 60-80 seconds.
Transition to oral anticoagulants once the
patient is stabilized (e.g., apixaban 10 mg twice daily for 7 days, then 5 mg
twice daily, or rivaroxaban 15 mg twice daily for 21 days, then 20 mg daily).
Alternatively, transition to warfarin with a target INR of 2-3.
Oxygen supplementation: Administer supplemental
oxygen via nasal cannula to maintain oxygen saturation > 92%. Consider
non-invasive ventilation if respiratory distress persists.
Pain management: Administer morphine for pain
relief if needed. NSAIDs can be considered for additional pain control.
Monitoring: Continuous monitoring of vital
signs, especially respiratory status and hemodynamics. Close monitoring for
signs of hemorrhagic complications due to anticoagulation.
Additional Interventions:
Thrombolytics: Consider thrombolytic therapy
(e.g., alteplase) if the patient develops hemodynamic instability or if the PE
is massive with signs of shock or right heart failure.
Mechanical support: In case of severe
hemodynamic compromise, consider embolectomy or inferior vena cava (IVC) filter
placement if anticoagulation is contraindicated.
Long-Term Management:
Anticoagulation: Continue anticoagulation
therapy for a minimum of 3-6 months or longer if the PE is unprovoked or if
there are recurrent events.
Lifestyle modifications: Encourage weight loss,
smoking cessation, and increased physical activity to reduce the risk of
further thromboembolic events.
Follow-up: Follow-up with a cardiologist and
pulmonologist in 1-2 weeks to monitor treatment efficacy, adjust
anticoagulation therapy, and ensure resolution of PE.
Education:
Educate the patient about the importance of
medication adherence, signs of bleeding (e.g., easy bruising, hematuria,
melena), and the need for regular monitoring of INR if on warfarin therapy.
Discuss the signs of recurrent PE, such as new
or worsening chest pain, shortness of breath, or coughing up blood, and
instruct the patient to seek emergency medical care if these symptoms occur.
Emphasize the need for lifestyle changes such
as smoking cessation, weight management, and increased physical activity.
Follow-up:
Initial follow-up in 1 week to assess clinical
progress and adjust anticoagulation therapy.
Continue regular monitoring of anticoagulation
therapy to ensure therapeutic levels are maintained.
Evaluate for possible post-PE syndrome,
including persistent dyspnea, exercise intolerance, and lower extremity
swelling, at subsequent follow-up visits.
Discussion:
Pulmonary embolism (PE) is a life-threatening
condition caused by the obstruction of the pulmonary artery by a thrombus. Risk
factors such as recent DVT, obesity, and sedentary behavior increase the risk
for PE, as seen in this patient. The initial management of PE centers on
anticoagulation therapy to prevent further clot formation and promote
resolution of the embolism. For patients with massive PE and hemodynamic
instability, thrombolytic therapy or surgical intervention may be necessary.
In this case, early identification of PE and
prompt anticoagulation are essential in improving outcomes. The patient will
require long-term anticoagulation therapy and regular follow-up to prevent
recurrent thromboembolic events.
تعليقات
إرسال تعليق