You’re on your post-partum rotation and are visiting a 35 yo obese G1P1 who recently had a C-section 24 hours ago. She complains of right sided pleuritic chest pain, palpitations and shortness of breath while lying in her hospital bed and reports feeling lightheaded and "uneasy" though she seems altered while you are speaking to her. She has a history of lupus and takes no medications currently. She smokes 2 PPD x 15 years.
What's next then? What should you always evaluate first and foremost? Vitals and Physical!
- Vitals: P 112 | RR 30 | BP 70/40 | SpO2 83%
- Physical Exam:
- Gen: Anxious, A&Ox3
- HEENT: PERRLA, EOMI, no LAD
- PULM: CTAB
- CV: Tachycardic, Regular Rate, No M/R/G
- ABD: + BS, no tenderness, guarding, rigidity or distension
- Skin: Incision site clean, dry, intact
What other information are you looking for? What studies are you looking for?
This is a patient who is likely having a pulmonary embolus. She is a young woman, recently post-partum with lupus and who smokes - all risk factors for a hypercoagulable state. Additionally her symptoms of pleurisy and tachycardia are classic for PE. While we all learn the classic S1Q3T3 for PE, it is important to note that the majority of PE’s will present with sinus tachycardia.
In the event of a PE, a thrombus is lodged in the pulmonary vasculature. This clogs up outflow from the right heart causing right ventricular dilation and scalloping of the free wall. This clog also causes fluid to back up into the IVC causing it to be plethoric. Another sign of PE is McConnell’s sign, where there is akinesia of the middle free wall of the RV but normal motion at the apex - this sign is 77% sensitive and 94% specific.
Now let’s say you didn’t have an ultrasound nearby so you start a bolus of saline and begin rolling her towards your hospital’s CT scanner. On the way she loses her pulses.