ElectricPE: The Diagnosis of Pulmonary Embolism: Case Study 22
Jeffrey R. Galvin, M.D. and James J. Choi, B.S.
Peer Review Status: Internally Reviewed
Her
temperature on admission to that hospital was 38. She was intubated
and placed on mechanical ventilation because of exhaustion. She was
started on antibiotics. Her condition stabilized but she remained
ventilator dependent. All sputum and blood cultures were negative and
she was transferred to this hospital. Her blood gases on admission
were: pH 7.44 PCO2 66 PO2 88% on mechanical ventilation (50% FIO@2).
The chest x-ray showed a hazy right upper lobe density.
In
addition, there is an endotracheal tube present
A chest CT done to look for reversible causes for the patients
respiratory failure such as a pneumothorax.
The study
demonstrated only right upper lobe consolidation. She was also found
to have a clot in a right upper lobe pulmonary artery on the
mediastinal images. 
A duplex Doppler exam of the legs to look for the source of her
embolus demonstrated deep venous thrombosis extending from the distal
femoral vein to the popliteal.
Case Assessment
This is a 59 year old female with severe underlying chronic
obstructive pulmonary disease who presented with rapidly increasing
dyspnea, cough, infiltrate, and fever.
Patients with severe COPD may decompensate for a number of reasons including: bronchospasm, infection, and fluid overload. It can be very difficult, as in this case, to make the diagnosis of pulmonary embolus with a background of severe emphysema. One clue is that these patients will hyperventilate and lower their PCO2. This test is helpful diagnostically, only if the patients baseline CO2, (which is often elevated) is known. Unfortunately, this information was not available for the current case.
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