45 year old female presents with a 2 day history of intermittent retrosternal chest pain, dyspnoea and exertional syncope.
She is otherwise normally healthy and does not smoke. Her regular medications are limited to an oral contraceptive pill and antidepressant. She leads a sedentary lifestyle and her work requires her to be seated for 10 hours every day. No recent long-haul travel or surgery. No personal or family history of venous thromboembolic disease.
Her vital signs in the emergency department are HR 84bpm, BP 62/32mmHg, RR 26 breaths/min, Sats 99% on 15L non-rebreather mask, temperature 36.7 degrees Celsius, GCS 15. Cool peripheries, distended neck veins. Chest clear. Abdomen soft, non-tender. Calves soft, non-tender. ECG demonstrates sinus rhythm with a q wave in lead III and T wave inversion in lead III. D-dimer is 4.
A CT Pulmonary Angiogram has been performed which demonstrates multiple, large bilateral pulmonary emboli originating in both the left and right pulmonary arteries and extending into all lobar branches and all segmental branches except the left upper lobe. Additionally, there is bowing of the interventricular septum inferior and contrast reflux into the IVC consistent with right ventricular strain. On the lung windows (not included) there is no consolidation to indicate pulmonary infarction.