Submassive Pulmonary Embolism

Information about a real patient is presented in stages (boldface type) to expert clinicians (Drs Louis J. Dell’Italia and David C. McGiffin) who respond to the information, sharing his or her reasoning with the reader (regular type). A discussion by the authors follows. A 67-year-old black woman presents to the emergency department with a 1-day history of dyspnea, which began the previous morning initially with moderate exertion now progressing to dyspnea at rest. She denies chest pain, cough, palpitations, nausea, diaphoresis, lower extremity swelling, paroxysmal nocturnal dyspnea, orthopnea, presyncope, or syncope. Her medical history is notable for hypertension, diabetes mellitus, and hypothyroidism. Her medications include metoprolol tartrate 12.5 mg twice daily, metformin 1000 mg twice daily, levothyroxine 25 μg daily, and estradiol 1 mg daily for symptomatic management of hot flashes. She lives alone and is a retired schoolteacher. She does not smoke, drink alcohol, or use illicit drugs. Family history is not significant. Travel history is notable for round-trip plane flight from Alabama to Utah, arriving home 2 days previously. On physical examination her temperature is 98.4°F, pulse is 94 beats/min, blood pressure is 112/55 mm Hg in the right arm, 110/58 mm Hg in the left arm, respiratory rate 26 breaths/min, and oxygen saturation 90% on room air. She is an obese black woman (body mass index 32 kg/m2) in mild distress secondary to shortness of breath. Jugular venous pressure is estimated at 14 cm H20. Lungs are clear to auscultation. The heart rhythm is regular with a normal S1 and S2. No murmurs, rubs, or gallops are appreciated. Peripheral pulses are brisk and symmetrical with trace pretibial pitting edema. Abdominal examination is benign. Dr Louis J. Dell’Italia: This patient presents with a 24-hour history of dyspnea progressing from symptoms with exertion to now occurring …