Pulmonary embolism with respiratory failure

CC: sudden SOB. HPI: 66M with CAD s/p PCI/DES to LAD (2021), HTN, HLD, insulin-requiring T2DM, former smoker, woke at 03:00 with abrupt SOB and L pleuritic chest pain. Unable to walk to bathroom without stopping. No leg pain. No recent surgery, immobilization or travel. ROS: + dyspnea, pleuritic CP, lightheaded. Denies fever, cough, hemoptysis, syncope. Vitals: T 37.2, HR 118, RR 28, BP 104/68, SpO2 82% RA. Exam: Diaphoretic, tachypneic, speaking 4-5 word sentences. Lungs clear bilaterally. Tachycardic, regular. No JVD. No LE edema or asymmetry. Labs: Troponin 0.03 -> 0.04. BNP 88. D-dimer >20. WBC 10.2, Hgb 14.6. Cr 1.1. Glucose 212. ABG on NRB: 7.48/30/68. ECG: sinus tach 116, S1Q3T3 absent, no ST elevation. CTA chest (prelim per radiology phone call): bilateral PE, no RV strain. MDM: Acute bilateral PE with severe hypoxemia, initially 82% RA, required 15L NRB to reach 92%. Intermediate-low risk by sPESI/troponin, no RV strain on CT, normotensive. Heparin bolus + infusion. Admit step-down.

EXAM: CT angiography chest with contrast. FINDINGS: Filling defects in the right interlobar and right lower lobe lobar arteries extending into segmental branches; additional filling defects in left lower lobe segmental arteries. RV/LV ratio 0.9. No septal flattening. Small peripheral wedge-shaped opacity RLL may reflect early infarct. No pleural effusion. Coronary calcifications with LAD stent. IMPRESSION: Bilateral pulmonary emboli, lobar and segmental. No CT evidence of right heart strain.

HPI: As per ED. 66M with abrupt dyspnea, SpO2 82% RA, RR 28, CTA bilateral lobar/segmental PE. PMH: CAD s/p DES LAD 2021, HTN, HLD, T2DM on insulin. Former smoker 30 pk-yr, quit 2019. Meds: aspirin 81 mg, atorvastatin 80 mg, metoprolol succinate 50 mg, lisinopril 10 mg, insulin glargine 24 u qHS, metformin 1000 mg BID. Exam: HR 102, RR 24, BP 112/70, SpO2 91% on 6L NC (weaned from NRB). Increased work of breathing at rest. Lungs clear. No edema. TTE (bedside, prelim): normal RV size and function, LVEF 55%. LE duplex: no DVT bilaterally. Assessment/Plan: 1. Acute bilateral pulmonary embolism, POA, without acute cor pulmonale - normal RV on echo. Unprovoked. Heparin infusion; transition to DOAC when stable. Age-appropriate cancer screening up to date (colonoscopy 2024). 2. Acute hypoxic respiratory failure secondary to PE - SpO2 82% RA, RR 28, required NRB, now 6L NC. Titrate O2 to > 90%, step-down monitoring. 3. CAD s/p PCI - no ACS; minimal troponin leak attributed to PE strain physiology rather than ischemia. Continue aspirin while on heparin per cardiology phone discussion, statin, beta-blocker. 4. HTN - continue metoprolol, hold lisinopril while soft BPs. 5. HLD - atorvastatin. 6. T2DM on insulin - glargine 18 u + SSI; hold metformin (contrast). Code: Full.

S: Less SOB at rest. Pleuritic pain improving. O: HR 94, RR 20, BP 122/74, SpO2 93% on 3L NC. Lungs clear. A/P: 1. Acute bilateral PE - stable on heparin. Plan apixaban tomorrow. 2. Acute hypoxic respiratory failure due to PE - improving, weaned 6L -> 3L. Ambulatory sat check tomorrow. 3. CAD s/p PCI, HTN, HLD - continue meds; resume lisinopril. 4. T2DM on insulin - glucose 150-200, glargine 22 u.

Ambulatory O2 assessment: At rest on RA SpO2 95%. Ambulated 150 ft on RA, lowest SpO2 92%, HR 98, mild dyspnea, resolved with rest. Patient tolerated well. Educated on apixaban, bleeding precautions; teach-back complete.

Admit: 09/16/2026 Discharge: 09/20/2026 Discharge diagnoses: 1. Acute bilateral pulmonary embolism (lobar and segmental), unprovoked, without acute cor pulmonale 2. Acute hypoxic respiratory failure secondary to pulmonary embolism, resolved 3. Coronary artery disease s/p PCI with DES to LAD 4. Hypertension 5. Hyperlipidemia 6. Type 2 diabetes mellitus on long-term insulin Hospital course: Presented with abrupt dyspnea, SpO2 82% on RA requiring NRB. CTA: bilateral lobar/segmental PE, no RV strain; echo normal RV. Duplex negative for DVT. Treated with heparin, transitioned to apixaban 09/18. O2 weaned to RA by 09/19; ambulatory SpO2 >= 92% on RA. Discharge meds: apixaban 10 mg BID x7 days then 5 mg BID; aspirin 81 mg (cardiology to reassess need with DOAC), atorvastatin, metoprolol, lisinopril, glargine 24 u, metformin. Follow-up: PCP 1 week; cardiology 2-4 weeks; hematology re: duration of anticoagulation for unprovoked PE.