Pulmonary Embolism-Beware Two Important Atypical Presentations

Seems like we have had several atypical PE presentations recently so I thought it timely to quickly highlight some of the well-reported presentations of pulmonary embolism. Remember, although we won't and can't diagnose every case, these types of presentations should at the very least prompt us to consider the diagnosis.

Atypical PE Presentations:

• Syncope-occurs in as many as 15-20% of patients. Make sure PE is on the differential diagnosis of the syncopal patient, especially if there was any preceeding shortness of breath or chest pain.
• Abdominal pain-we just had a case of this last week. A young female 6 weeks into a course of OCPS developed RUQ pain that radiated to the left shoulder. She had NO shortness of breath. However, the RUQ pain was pleuritic. Remember the movement of the diaphragm as it is responsible for abdominal pain presentations of both PE and pneumonia. A d-dimer was obtained and returned 3000. A CT scan was then ordered which showed a large right lower PE. What's the moral of the story? Well, it isn't to rule out PE in patients with belly pain. The lesson here is that upper abdominal pain may reflect disease in the chest (lower lobe pneumona and PE) and vice versa. To make matters worse an ultrasound of the RUQ was ordered 1st which showed gallstones!