ElectricPE: The Diagnosis of Pulmonary Embolism: Case Study 9
Jeffrey R. Galvin, M.D. and James J. Choi, B.S.
Peer Review Status: Internally Reviewed
His chest x-ray showed only a slightly enlarged heart.
Diagnostic blood tests obtained in the intensive care unit
determined that Case #9 did not have a myocardial infarction and he
was referred for a cardiac function study to look for regional wall
motion abnormalities. The study was done on an electron beam scanner
that acquires near real time cross sectional movies of the heart.
The upper
images were obtained at the level of the pulmonary arteries. These
are shown as contrast filled structures . The free end of a clot was
identified on these first images with arrow. The next anatomic level
shows that the clot completely occludes the right pulmonary artery.
The perfusion scan shows multiple wedge-shaped segmental perfusion
defects. 
The ventilation scan shows homogenous distribution of radiotracer.
This was
therefore a classic high probability perfusion scan.
Case Assessment
This is a 65 year old man who presents with syncope and mild
substernal chest pain.
1. PE patients who present with syncope usually have suffered a
large embolus. Syncope results from a significant drop in cardiac
output and that implies that more than 50% of the pulmonary
vasculature has been blocked as in this case.
2. The history and physical in patients with pulmonary embolus is often non-specific. (REFERENCE) This case is an excellent example of the difficulty in recognizing the variable presentation of PE. The real diagnosis in this patient was not considered until the clots were visualized during the cardiac function scan.
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