Scenario: CHF and Pulmonary Embolism Example

Scenario Details 

Chief Complaint 

• “I was in the hospital last week with a blood clot in my lung, and was told at discharge that I need to have my blood checked to see if it is thin enough. My right chest still hurts, though it is better, and I am still more short of breath than usual.” 

History 

• 72-year-old female seen 1 week earlier in ED with history of sudden onset right sided chest pain and shortness of breath which had started 3 hours prior to arrival. Pain was made worse with deep inspiration. Exam at that time showed vital signs of P 110 and regular, BP 140/102, T. 98.6, RR 26, SAO2 83% on oximetry, breathing room air. Physical exam showed swollen R lower extremity which was painful and warm to the touch. A pleural friction rub was heard over the right lower chest, posteriorly. Doppler ultrasound of right lower extremity shows deep vein thrombosis. Pulmonary CT Angiography showed total occlusion of RLL artery, as well as signs of chronic pulmonary artery hypertension. 

• Patient diagnosed with hypertensive heart disease with mild chronic left ventricular diastolic failure and mild pulmonary artery hypertension 2 years previously. Has been well managed on ARB therapy without complications. 

Review of Systems, Physical Exam, Laboratory Tests 

• P 84, regular, BP 132/96,T 98.4, RR 22, SAO2 89% by oximetry on room air 

• Chest: dullness to percussion over RLL posteriorly with decreased breath sounds in same area • Right lower calf mildly swollen but not warm or tender 

• CXR: moderate sized pleural effusion on R 

• Lab: INR 3.2 on Coumadin 10 mg/day (preferred range 2.0-3.0) 

Assessment and Plan 

• Acute RLL Pulmonary Embolism: continue Coumadin but reduce dose to 5 mg/day

• Acute Right Side Pleural Effusion, presumed secondary to P.E.: follow in 2 weeks with repeat chest x-ray 

• Acute Deep Vein Thrombophlebitis of right leg: continue Coumadin at 5 mg/day 

• Acute Respiratory Failure with Mild Hypoxemia: arrange home oxygen at 2L/min by nasal cannula • Hypertensive heart disease with Chronic mild left ventricular diastolic failure: continue ARB therapy 

• Chronic mild pulmonary artery hypertension 

• Over anti-coagulation: reduce Coumadin to 5 mg/day, check INR in 4 days