IM Board Review

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

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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 (V 1–V3), and biphasic T waves in lead V 4,, 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.

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