A 65-Year-Old Woman With a 2-Day History of Unilateral Calf Swelling and Dyspnea

HPI: A 65 year-old woman presented to the Emergency Department with a 2 day history of unilateral calf swelling and dyspnea after a 10 hour car trip.
PMH: Hypertension and Hperlipidemia
Meds: Atenolol 50 mg and Simvistatin 20 mg
SH: 50 pack-year smoking history
PE: BP 95/60 mmHg, hr- 105 bpm, RR- 24 breaths/min, Oxygenation saturation room air 86 %
Heart: tachycardic, no murmurs, JVP- normal
Lungs: clear
Extremities: right calf is swollen, erythematous, and tender

ECG: Incomplete RBBB, otherwise normal
CXR: hyper-inflated lungs
Lab studies: Arterial blood gas revealed pH 7.47, Pco2 28 mmHg, and Po2 of 55 mmHg on room air
cTnI: 0.6 ng/ml (99th % 0.04 ng/ml), BNP 650 pg/ml ( reference range < 200 pg/ml).

Treatment: Patient received an IV bolus of 500 cc 0.9 NS and repeat BP was 100/60 and heart rate 100 bpm. Patient was started on oxygen 2 L/min and received IV heparin.

CT scan: Image quality was suboptimal due to patient movement. However, it demonstrated acute pulmonary embolism in the right and left pulmonary arteries with extension into the right upper, right lower, left upper, and left lower segments.  Unable to comment on RV strain; RV size appeared at the upper limit of normal.

Tranthoracic Echocardiogram: Technically difficult study. Left ventricle appears to be hyperdynamic, The right ventricle was not well-visualized and unable to estimate the systolic pulmonary artery pressure.

Hospital Course: Patient was admitted to the Intensive Care Unit at 6:00 PM. At 10:00 PM oxygen requirements increased requiring a 50% venti-mask to maintain a saturation > 90%. BP is 95/60 mmHg with heart rate of 110 bpm. The patient had adequate urine output and normal mental status.

At this point what would you recommend for the management of this patient?

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