Chronic PE, Echo with increased Pulmonary Pressure, Abnormal PFT, Persistant Chest pain and SOB

[ellamargomom]

I am a 30 yo WF with a hx of DVT.  I had one last year post surgery.  I developed one four weeks ago in the popliteal vein on my right side.  Four days after diagnosis I developed DOE, Chest pain, heart palpitations.  I was admitted to the ER.  CT scan results: small stellate filling defect within the right lower lobe pulmonary artery suggestive of chronic PE.  Right greater than left atelectasis, small right pleural effusion, contrast reflux into the right inferior vena cava please correlate with right sided heart failure.  

Two weeks before this diagnosis of DVT and then CT results, I was in the PCP office with chest pain.  He had a VQ scan performed.  The VQ scan was negative.  

I was admitted to the ICU for two days.  My ECG shows first degree AV block.  Echo: the doc said it was normal.  Trivial tricuspid valvular regurgitation. trivial pulmonic regurgitation. Pulmo. artery pressures at 33.  Estimated RV systolic pressure at 33. LV EF: 73%  Estimated CVP: 10

Summary of findings: Estimated pulmonary artery peak systolic pressure was 33mmHg
Overall left ventricular systolic function was normal. Left Vent. EF was estimated to be 65% There was no diagnostic evidence of left ventricular regional wall motion abnormalities.  Left ventricular diastolic function parameters were normal.  There was normal estimated mean pulmonary artery pressure by doppler acceleration time.  

On exam: systolic ejection murmur right upper sternal border, right lower sternal border, and apex does not radiate to neck. Grade 1-2/6

BTW..I am a nurse.  I continue to get SOB with any type of exertion.  My latest INR was at 2.1 down from 4.4 after they overloaded me with coumadin due to a slow response.  There are times when my chest starts hurting and I become diaphoretic and the pain radiates to the left arm.  

The doctor has been blowing me off.  I am also having headaches after exertion.  

I appreciate your help.

Thanks.

[Douglas Bogart, MD]

You should be on long term warfarin with a history of DVT and now pulmonary emboli. By the echo your pulmonary artery pressure is minimally elevated.  The echo should be monitored for further changes in the PA pressure and right heart function.  You have mild orthostatic hypotension which may be secondary to your recent illness.  This should be monitored and potentially thigh length support hose might be of value.  If you are not getting the answers you need --get a second opinion.

[ellamargomom]

One more thing...sorry..I have been having increasing dizziness with changes in position.. Had another nurse on the floor do orthostatic readings and they were odd.  

Lying: 128/82  P: 90
Sitting: 118/98  P: 108
Standing: 102/100  P: 116

Sorry to dump so much information.  We repeated this again and the same readings were found by another nurse.  I have heard of orthostatic hypotension, but ortho hyper?  

Thank you so much

[ellamargomom]

I forgot to add that I am a non-smoker, social drinker (1-2 glasses of wine a week) and not obese.  Also the CT showed sub cm mediastinal lymph nodes.  My ESR was in the forties but has returned to normal.  CRP is mildly elevated.  H&H are stable.  

Also, I have been having pretty severe edema in my hands.  Does not seem to correlate with food intake.  I eat a pretty regular vegetarian diet.  Low in salt.  Just seems to be there when I wake up.  When I lie on my right side, I get increasing chest pain and palpitations.  

TSH and T4 are jumping all over the place.  I had my thyroid removed 7 years ago.  Have been on the same dose of Synthroid for years.  My TSH within a few weeks time went from 4.2 to 5.17 to 0.71 T4 was abnormal at first but is now normal with last lab.  

Med List: Mirapex 1 mg QHS  (RLS)
Synthroid: 200 MCG QD
Coumadin 5 mg QD
Omeprazole: QD
Neurontin: 2 QHS (RLS)

Thanks again.