A 50-year-old female patient presented to the emergency department with a 3-week history of cough and mild shortness of breath that started shortly after she returned from a European vacation.
She initially attributed her symptoms to seasonal allergies to pollen, as it was that time of year here in Minnesota when she returned. However, the antihistamines and steroids prescribed by her doctor helped with the nasal congestion, but did nothing for the shortness of breath and cough.
In fact, she felt like the shortness of breath seemed to be worsening. She was not able to do her usual level of activity without having to stop and rest. She denied fever, chest pain, hemoptysis, or recent illness. Her past medical history was also unremarkable, except for beginning hormone replacement therapy (HRT) 2 months prior.
On arrival, her airway, breathing, and circulation were all normal. Vital signs were within normal limits, including an oxygen saturation of 95% on room air. Physical examination revealed clear lung sounds without wheezes, crackles, or rhonchi. No peripheral edema or signs of deep vein thrombosis were noted.
Given her persistent symptoms and recent HRT use, a D-dimer was obtained (a blood test used to detect clots), and found to be positive. A subsequent CT pulmonary angiography demonstrated several small pulmonary emboli. She was started on anticoagulation, and the HRT was discontinued.
A pulmonary embolism or PE is defined as a condition where a blood clot (or medically referred to as an embolus) travels from another part of the body, usually from a vein in the legs, to one or more pulmonary arteries. The development of a blood clot in a deep vein is referred to as a venous thromboembolism or VTE. The incidence of VTE is about 1-2 per 1000, with a mortality rate in the US of about 60,000-100,000 deaths per year.
Virchow’s triad: venous stasis, endothelial injury, and hypercoagulability, describes the three interacting conditions that make a venous thrombus likely to form.
In this patient’s case, she had developed a hypercoagulable state due to the HRT, a known risk factor of HRT. She had also had venous stasis in her deep leg veins during prolonged sitting on the plane from Europe, another risk factor.
The clinical manifestation of PE depends on a dynamic interaction between the embolus (size, number, location), the patient’s baseline cardiopulmonary status, and therefore, the hemodynamic response. Presentations can range from silent or incidental findings to sudden cardiac arrest.
This case highlights the fact that normal vital signs, and a benign physical exam do not rule out a PE. This case also reveals the importance of evaluating for risk factors in a patient’s story and having a high index of suspicion. Listen to your patients’ stories for clues.
She initially attributed her symptoms to seasonal allergies to pollen, as it was that time of year here in Minnesota when she returned. However, the antihistamines and steroids prescribed by her doctor helped with the nasal congestion, but did nothing for the shortness of breath and cough.
In fact, she felt like the shortness of breath seemed to be worsening. She was not able to do her usual level of activity without having to stop and rest. She denied fever, chest pain, hemoptysis, or recent illness. Her past medical history was also unremarkable, except for beginning hormone replacement therapy (HRT) 2 months prior.
On arrival, her airway, breathing, and circulation were all normal. Vital signs were within normal limits, including an oxygen saturation of 95% on room air. Physical examination revealed clear lung sounds without wheezes, crackles, or rhonchi. No peripheral edema or signs of deep vein thrombosis were noted.
Given her persistent symptoms and recent HRT use, a D-dimer was obtained (a blood test used to detect clots), and found to be positive. A subsequent CT pulmonary angiography demonstrated several small pulmonary emboli. She was started on anticoagulation, and the HRT was discontinued.
A pulmonary embolism or PE is defined as a condition where a blood clot (or medically referred to as an embolus) travels from another part of the body, usually from a vein in the legs, to one or more pulmonary arteries. The development of a blood clot in a deep vein is referred to as a venous thromboembolism or VTE. The incidence of VTE is about 1-2 per 1000, with a mortality rate in the US of about 60,000-100,000 deaths per year.
Virchow’s triad: venous stasis, endothelial injury, and hypercoagulability, describes the three interacting conditions that make a venous thrombus likely to form.
In this patient’s case, she had developed a hypercoagulable state due to the HRT, a known risk factor of HRT. She had also had venous stasis in her deep leg veins during prolonged sitting on the plane from Europe, another risk factor.
The clinical manifestation of PE depends on a dynamic interaction between the embolus (size, number, location), the patient’s baseline cardiopulmonary status, and therefore, the hemodynamic response. Presentations can range from silent or incidental findings to sudden cardiac arrest.
This case highlights the fact that normal vital signs, and a benign physical exam do not rule out a PE. This case also reveals the importance of evaluating for risk factors in a patient’s story and having a high index of suspicion. Listen to your patients’ stories for clues.
References:
Turetz M, Sideris AT, Friedman OA, Triphathi N, Horowitz JM. Epidemiology, Pathophysiology, and Natural History of Pulmonary Embolism. Semin Intervent Radiol. 2018 June. https://pmc.ncbi.nlm.nih.gov/articles/PMC5986574/ accessed September 5, 2025.
Vyas V, Sankari A, Goyal A. Acute Pulmonary Embolism. [Updated 2024 Dec 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK560551/ accessed September 2, 2025.
