Other / General Medicine
Nazia Hossain, MD
PGY3 resident
University of Miami Miller School of Medicine/Jackson Health System
Miami, Florida, United States
Dylan Wood, MD
Resident Physician
University of Miami
Miami, Florida, United States
Diana Molinares, MD
Associate Professor, Program Director
University of Miami Miller School of Medicine
Miami, Florida, United States
Nazia Hossain, MD
University of Miami Physical Medicine & Rehab
Miami, Florida, United States
A pulmonary embolism (PE) is an acute life-threatening condition that typically presents with shortness of breath, chest pain, tachycardia and more. Patients with malignancy, recent surgery, clotting disorders and prolonged immobility are at higher risk of PE.
Case Description:
A 26 year old man with history of stage IV metastatic melanoma presented to an acute rehabilitation facility (ARF) ten days status-post left frontal craniotomy for resection of hemorrhagic metastasis. On admission, the patient was clinically stable at room air. On day two of ARF stay, the patient reported moderate right upper quadrant (RUQ) pain. Abdominal exam was benign and the pain resolved on its own. RUQ pain returned several days later and a RUQ ultrasound was ordered which showed hepatomegaly, but no other significant pathology. The following morning, the patient had worsening RUQ pain and new onset tachypnea and hypoxia requiring 3L of oxygen via nasal cannula. Chest CTA was ordered by the rehabilitation team and revealed acute PEs in bilateral lungs with evidence suggestive of right heart strain. The patient was started on therapeutic enoxaparin and subsequently transferred back to the acute hospital for further management.
Discussions: Patients in ARF have a high risk of PE due to recent surgeries, prolonged immobility and multiple co-morbidities. This case highlights the importance of maintaining a high degree of clinical suspicion for PE even in the presence of uncommon symptoms. RUQ is an unusual presentation of PE; possible hypotheses for this presentation include diaphragmatic pleurisy or hepatic congestion from backflow caused by the clot. Close monitoring of vital signs and proper work-up for new symptoms is imperative.
Conclusions: PEs are a life threatening condition commonly seen in ARF. Prompt diagnosis and management is crucial and providers should maintain a high level of suspicion even with atypical symptoms.
