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A massive pulmonary embolism with heart strain in urgent care

A 44-year-old male with no significant past medical history self-presented to a community urgent care (UC) complaining of a four day history of shortness of breath, made worse by exertion. Three weeks prior to presentation, the patient underwent arthroscopic surgery on his left knee, and was then sedentary for two weeks following the procedure. He also reported that he travels long distance by car two to three times a week for work, as well as a recent plane trip. His presentation and history made clinicians concerned for pulmonary embolism (PE), so he was transferred to the neighboring emergency department (ED) associated with the UC. Upon arrival to the ED, his vital signs included blood pressure 116/86 mmHg, pulse 116 bpm, respirations 16, temperature 36.6°C, and oxygen saturation 95% on room air. A D-dimer was obtained and found to be significantly elevated at 9650 ng/mL. A computed tomography angiogram (CTA) of the chest was obtained (Figures 1–3) which revealed a massive pulmonary thromboembolism with thrombus burden in the bilateral lobar, segmental, and subsegmental branches of all five lobes as well as evidence of right heart strain. A heparin drip was initiated and the patient was admitted to the medical intermediate care service in consultation with the vascular surgery team. A transthoracic echocardiogram revealed a dilated right ventricle with moderately decreased systolic function, septal flattening consistent with right ventricular pressure overload, moderate tricuspid regurgitation, and severe pulmonary hypertension all thought to be secondary to significant clot burden and expected to improve with anticoagulation.