CC: SOB, R leg swelling.
HPI: 58F with HTN, HLD, hypothyroidism, GERD, obesity presents with 2 days of exertional SOB and 5 days of R calf/thigh swelling and ache. Returned 6 days ago from a 14-hour flight from Singapore. No prior VTE. No hormone therapy. No known malignancy; colonoscopy and mammogram up to date.
ROS: + DOE, R leg pain/swelling, mild pleuritic L chest pain. Denies syncope, hemoptysis, fever.
Vitals: T 37.0, HR 104, RR 20, BP 146/88, SpO2 95% RA.
Exam: Mild tachypnea, lungs clear. RRR. R thigh and calf swollen (R calf 4 cm > L), tender along femoral vein. Distal pulses intact.
Labs: D-dimer 4.8. Troponin <0.01. BNP 42. CBC, BMP unremarkable; Cr 0.8.
CTA chest (prelim per radiology phone call): segmental PE RLL and LLL, no RV strain.
MDM: Acute PE, provoked by long-haul travel, hemodynamically stable, sPESI 0. Heparin drip started. Admit for anticoagulation and LE duplex.
EXAM: CT angiography chest with contrast.
FINDINGS: Filling defects in segmental branches of the right lower lobe and left lower lobe pulmonary arteries. Main and lobar arteries patent. RV/LV ratio 0.8; no septal bowing; no reflux of contrast into the IVC. No infarct. No effusion. Small hiatal hernia.
IMPRESSION: Bilateral segmental pulmonary emboli without CT evidence of right heart strain.
HPI: As per ED. Travel-associated bilateral segmental PE.
PMH: HTN, HLD, hypothyroidism, GERD, obesity.
Meds: losartan 50 mg, rosuvastatin 10 mg, levothyroxine 100 mcg, pantoprazole 40 mg.
Social: Accountant, never smoker, rare EtOH.
Exam: Wt 98 kg, Ht 165 cm, BMI 36.0. HR 96, SpO2 96% RA. R leg edema/tenderness.
Assessment/Plan:
1. Acute bilateral segmental pulmonary embolism, POA, without right heart strain - heparin gtt per protocol; transition to DOAC once duplex done and stable.
2. R leg swelling, suspect DVT - LE venous duplex in AM.
3. HTN - continue losartan.
4. HLD - continue rosuvastatin.
5. Hypothyroidism - continue levothyroxine.
6. GERD - continue PPI.
7. Obesity, BMI 36 - counseling.
Code: Full.
EXAM: US venous duplex, bilateral lower extremities.
FINDINGS: RIGHT: Noncompressible, expanded femoral vein with occlusive echogenic thrombus from the proximal to distal femoral vein. Common femoral, popliteal, and calf veins compressible with normal flow. LEFT: Normal compressibility and flow throughout.
IMPRESSION: Acute occlusive deep vein thrombosis of the right femoral vein.
S: SOB improving, leg pain better with elevation.
O: HR 84, RR 16, BP 132/80, SpO2 97% RA. R leg edema persists, less tender.
A/P:
1. Acute bilateral segmental PE - stable on heparin; transition to apixaban 10 mg BID x7d then 5 mg BID today.
2. Acute DVT, R femoral vein, POA - source of PE; on anticoagulation as above.
3. HTN, HLD, hypothyroidism, GERD, obesity - stable, home meds.
Anticoagulation transition consult. Heparin infusion stopped 13:30; apixaban 10 mg PO given 13:30. Wt 98 kg, CrCl ~105 mL/min, no interacting CYP3A4/P-gp agents on med list. Plan: apixaban 10 mg BID x7 days (through 09/22) then 5 mg BID. Counseled patient on missed doses, bleeding signs, avoidance of NSAIDs, and to inform dentist/surgeons. Copay verified affordable; 30-day free trial card provided. Patient verbalized understanding via teach-back.
Admit: 09/15/2026 Discharge: 09/18/2026
Discharge diagnoses:
1. Acute bilateral segmental pulmonary embolism without right heart strain, provoked (long-haul travel)
2. Acute deep vein thrombosis, right femoral vein
3. Hypertension
4. Hyperlipidemia
5. Hypothyroidism
6. GERD
7. Obesity, BMI 36
Hospital course: Presented with dyspnea and R leg swelling after a 14-h flight. CTA: bilateral segmental PE, no RV strain; troponin/BNP normal. Duplex: occlusive R femoral DVT. Treated with heparin gtt then apixaban. Never hypoxic, remained hemodynamically stable.
Discharge meds: apixaban 10 mg BID through 09/22 then 5 mg BID for at least 3 months; home losartan, rosuvastatin, levothyroxine, pantoprazole.
Follow-up: PCP 1 week; hematology 3 months to decide duration.