A 75-year-old with abdominal pain, hypoxia, and weak pulses in the left leg

Cleveland Clinic Journal of Medicine. 2018 February;85(2):145-154 | 10.3949/ccjm.85a.16069
February 1, 2018|Cleveland Clinic Journal of Medicine
Maya Serhal, MD;Natalie Evans, MD, RPVI;Heather L. Gornik, MD, RVT, RPVI
Author and Disclosure Information

Maya Serhal, MD
Vascular Medicine Section, Department of Cardiovascular Medicine, Cleveland Clinic

Natalie Evans, MD, RPVI
Vascular Medicine Section, Department of Cardiovascular Medicine, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Heather L. Gornik, MD, RVT, RPVI
Medical Director, Non-Invasive Vascular Laboratory, Vascular Medicine Section, Department of Cardiovascular Medicine, Cleveland Clinic; Associate Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Address: Maya Serhal, MD, Department of Vascular Medicine, J3-5, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44195; Serhalm@ccf.org

Dr. Gornik has disclosed she was a site principal investigator in the Examining Use of Ticagrelor in Peripheral Artery Disease (EUCLID) trial, funded by AstraZeneca.

A 75-year-old man presented to the emergency department for evaluation of abdominal pain. He had stage 3 chronic obstructive pulmonary disease (COPD), with a forced expiratory volume in 1 second of 33%.

PREVIOUS HOSPITALIZATION

Aside from his COPD, he had been healthy until 1 month earlier, when he had been hospitalized because of shortness of breath and chest pressure with exertion. His troponin T level had been elevated, peaking at 0.117 ng/mL (reference range 0–0.029).

Left heart catheterization had shown no significant coronary artery disease. A myocardial bridge of the distal left anterior descending coronary artery had been seen, so that the artery appeared to be narrowed by 50% to 60% with ventricular contraction. But this was not thought to have been the cause of his presentation.

On discharge, he required oxygen 4 L/min by nasal cannula. Previously, he had not needed supplemental oxygen.

CURRENT PRESENTATION

The patient described persistent and severe periumbilical abdominal pain during the previous day. It was not associated with eating, and he denied diarrhea, constipation, hematemesis, hematochezia, bright red blood per rectum, or melena. He continued to describe persistent shortness of breath and pleuritic chest pain. His vital signs were as follows:

  • Heart rate 104 beats per minute
  • Respiratory rate 16 to 20 breaths per minute
  • Blood pressure 101–142/62–84 mm Hg
  • Oxygen saturation 78% on room air.

The patient's laboratory data on presentation
He was placed on oxygen by a Venturi mask, and his oxygen saturation improved to 93%.

The patient’s electrocardiogram on presentation.
Figure 1. The patient’s electrocardiogram on presentation. Arrows point to notable features (see text).
On examination, his lungs were clear bilaterally. His abdomen was diffusely tender but without peritoneal signs. His left lower leg was cool to touch, and his left dorsalis pedal and posterior tibial pulses were only weakly palpable. His right leg pulses were normal. He denied pain in the lower extremities. No jugular venous distention was noted, and cardiac examination was most notable for tachycardia.

His laboratory findings on presentation are shown in Table 1, and his electrocardiogram is shown in Figure 1.

WHAT DOES HIS ELECTROCARDIOGRAM SHOW?

1. Which of the following is the most accurate description of this patient’s electrocardiogram?

  • Sinus tachycardia, peaked P waves (P pulmonale) in lead II, and T-wave inversions in the right precordial leads
  • Sinus tachycardia and left bundle branch block
  • Sinus tachycardia and poor R-wave progression
  • Sinus tachycardia and ST elevation in the precordial leads

Our patient’s electrocardiogram shows sinus tachycardia, P pulmonale, T-wave inversion in the right precordial leads (V1–V3), and biphasic T waves in lead V4,, which suggest right ventricular strain.

The rhythm most commonly seen in patients with pulmonary embolism is sinus tachycardia, followed by nonspecific ST-segment or T-wave abnormalities. In one series of patients with acute pulmonary embolism, the classic findings of P pulmonale, right ventricular hypertrophy, right axis deviation, and right bundle branch block were rare (< 6%).1 Thus, these classic findings are not sensitive for the diagnosis of pulmonary embolism, and their absence does not rule it out.

Further studies for our patient

Computed tomography (CT) with a chest pulmonary embolism protocol showed filling defects.
Figure 2. Computed tomography (CT) with a chest pulmonary embolism protocol (top) showed filling defects (arrows). CT of the abdomen and pelvis showed renal artery thrombosis (arrow).
Computed tomography of the chest, abdomen, and pelvis with contrast was performed (Figure 2) to evaluate the patient’s chest pain, shortness of breath, and abdominal pain. It revealed bilateral pulmonary emboli, with filling defects in the distal right and left main pulmonary arteries extending into the lobar branches of the right upper, middle, and lower lobes and left upper and lower lobes; multiple subsegmental pulmonary emboli were also seen. The patient was also found to have evidence of a left renal infarction, with an extensive filling defect in the left renal artery, consistent with renal artery thrombosis.

Transthoracic echocardiography was performed to look for evidence of right ventricular strain secondary to the pulmonary embolism.