James Smith is a 64-year-old white male and a retired truck driver who presented to the ED with complaints of shortness of breath and chest pain. He states he started feeling light-headed yesterday and experiencing a sharp, knife-like pain in his chest two hours ago (which prompted him to come to the ED). He presents with circumoral cyanosis and 3+ pitting edema of the right lower extremity. Mr. Smith states that he also has an intense cramping in his right calf and states that it started two weeks ago. He rates his pain a 10/10. Vital signs were taken. Oxygen saturations are 86% on room air, respiratory rate 26 breaths per minute, heart rate is 108, oral temperature 99.1, and a blood pressure of 181/93. Patient denies any significant changes in weight; his last weight was two days ago at his primary care provider’s office weighing 130 kg. Current weight 129.7 kg. Auscultation of the lungs revealed diminished, yet equal lung sounds with no crackles noted.
Upon reviewing home medications, Mr. Smith states he doesn’t take his medication because he “cannot afford it.”
Past Medical History
Hypertension (diagnosed 3 years ago)
CVA (five years ago)
Bilateral lower-extremity DVT (2 years ago)
Pertinent Surgical History
None
Pertinent Family History
Mother had Factor V Leiden and passed away from a stroke at age 71
Father is still alive and well at age 87
Pertinent Social History
4-pack a day smoker for 46 years
Enjoys taking long road trips across the country
Labs/Diagnostic Tests
Positive D-dimer results
Chemistry: Sodium: 138, Potassium: 3.9, Chloride: 101, BUN: 8, Creatinine: 1.3, Bicarbonate: 24
CBC: WBC: 8, Hgb: 13.5, Hct: 40.5, Platelets: 637
B-type Natriuretic Peptide: 124 pg/ml
Troponins: 1st: 0.02 ng/ml, 2nd: 0.01 ng/ml, 3rd: 0.01 ng/ml
Chest X-ray: Negative for infiltrates/consolidation. No atelectasis noted. No air or fluid viewed in the pleura cavity. No cardiomegaly noted.
EKG: sinus tachycardia without ST elevation or ST depression.
ECHO performed showed an ejection fraction of 64%.