A Complicated Clot

A 45-year-old female patient with no significant past medical history presented with a chief complaint of syncope. The event occurred while she was ambulating in the bathroom. She endorsed prior to loss of consciousness feeling symptoms of severe shortness of breath as well as lightheadedness described further as pre-syncope. The patient awoke on the ground after the episode and immediately called emergency medical services. Of note, prior to the episode, the patient endorsed a 1-week history of worsening dyspnea on exertion. At baseline, she was without functional limitations. However, over the past week, she endorsed progressively worsening dyspnea with minimal ambulation. She denied any associated chest pain, orthopnea, or lower extremity edema. Her only medications were oral contraceptives. She did not use tobacco or illicit drugs, and her alcohol intake was mild. Her pertinent physical and laboratory exams results follow:

  • Body mass index: 46
  • Blood pressure: 127/83
  • Pulse: 112
  • Respiration rate: 18
  • O2 saturation (2L NC): 95%
  • General: Alert, oriented, anxious
  • Cardiovascular: Regular tachycardia, normal S1/S2, no heaves/murmurs/gallops, normal jugular venous pulsation
  • Pulmonary: Clear to auscultation bilaterally, mild tachypnea, no rales/wheezes/crackles
  • Extremities: trace lower extremity edema with 2+ bilateral DP/PT pulses. No erythema, asymmetry, or palpable cords
  • Blood urea nitrogen/creatinine: 10/0.88 mg/dL
  • Pro-B-type natriuretic peptide (proBNP): 249 pg/mL (normal <125)
  • Troponin I: 0.559 ng/mL (normal <0.19)

Figure 1: Patients' Electrocardiogram

Figure 1

Figure 2A: Chest Computed Tomography (CT) With Intravenous Contrast

Figure 2A

Figure 2B

Figure 2B

What is the next most appropriate step in diagnosis or therapy?

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