r/emergencymedicine • u/Repulsive_Knee1304 • Jul 24 '25

Advice Missed PE, patient died

Throwaway account as to be expected.

I had a younger obese smoker male patient come in recently for shortness of breath that was exertional in nature, he said it started after he recently started working out. Patient was a smoker, 1/2 pack a day. SOB Resolved upon rest. patient states that he was carrying some heavy containers at work today, and noticed the shortness of breath again. No chest pain. No diaphoreses . No fever. No lower extremity swelling. No recent uri. Perc negative. Low pretest probability. Physical exam was significant for an expiratory wheeze, diminished sounds at bases. Patient got Breathing treatments, steroids and felt better. Reexamination showed improved aerations. Patient was discharged on steroids, albuterol. EKG NSR rate of 74, t wave inversions in v1-v3. No inversion in lead 3. No st changes. Cxr portable showed poor inspiratory effort, cardiomegaly( rotational?) but read as normal by radiologist and myself. Completely stable vitals. O2 sat of 95%, no tachy. No chest pain. Sob got better. Perc negative. Patient died at home 2 days later. Someone said PE. My guilt is consuming me. How fucked am i

EKG- S1,small q3. No t wave inversions in III. So no t3. Sinus rythym rate of 74 Qrs 88. Upright axis V1-v3 t wave inversions. No previous to compare to

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u/Successful-Tone-548 Jul 24 '25

PGY 32 here. I've come to have great respect for isolated SOB that isn't clearly decompensated asthma or COPD. The dd for SOB has a greater breadth than for chest pain. I go on fishing expeditions when I encounter that, especially in young adults. One case that comes to mind was a pudgy 32 year old man who started feeling mildly SOB sitting at his desk. Nothing else. No risks for anything. Normal vitals and exam. I ordered a CT because it didn't add up. He had a large aortic aneurysm. Air shipped him to a university medical center that successfully grafted it. Saved a life. Four months later when I was working the ambulance brought in a man in full arrest. He was DOA. I recognized him. It was the guy with the aneurysm.

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u/ahem96 Jul 24 '25

damn... he got 4 extra months i guess

12

u/Historical_Box9654 Jul 24 '25

I agree with your take that unexplained dyspnea is a red flag- but how is an unruptured aneurysm related? Unless causing mass effect or something…

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u/cosmin_c Physician Jul 25 '25

It was probably either mass effect or an actual incidental finding and his initial SOB was caused by something else (?random arrythmia) which eventually killed him, hell knows at this point.

7

u/circular159 Jul 25 '25

100% agree. Isolated SOB can be super deceptive and the ddx is way broader than we usually think. Sometimes you just gotta trust your gut when things feel off, even if the workup doesn’t scream red flags.