Near Miss

PG is 89 and lives alone; she comes in by ambulance with mild, new confusion that her son noticed when he went to say hello to her as he did every morning. When asked, she did complain of some severe chest pain that had occurred earlier, but there was no syncope, and right now she feels OK. She has no fever or headache, and her pre-hospital course was uneventful. Hypothyroidism was her only stated history, keeping with the maxim that if you show up past the age of 80 with almost no medical problems to the ED, something major must be wrong.

Her exam is pretty unremarkable; T 97.9 F, HR 67, BP 187/85, RR 18 (meaning no one checked, but seemed about right), SpO2 88% on RA. No real pertinent findings; lungs were clear, pulses good, no fever. She has a hard time telling me what day it is, but otherwise is good and conversant. Her pulse ox reverts to normal with only 2 L nasal cannula.

My standard old, sick work-up commences, and she comes back with a troponin of 0.11, which is suggestive of something going on, and with an LBBB on EKG, I suspect NSTEMI; confusion or altered mental status in the elderly is a very common presentation of acute coronary syndrome, and the severe chest pain earlier in the day makes it look like that as well. Lactate normal, not septic, doesn't need an LP, admit, done.

Just before she is taken upstairs, she tries to get up to go to the commode; as soon as she rises and pivots, she complains of central chest pain and relatively severe shortness of breath with discomfort. I attribute this to cardiac causes; she doesn't syncopize or have any other change in vital signs.

She wanders through her hospital course for a few days, and three days later, after a relatively normal echo with only a mildly dilated RV and no change in vital signs, someone gets a D-Dimer. Of course, it's up; and her CT shows a freaking saddle embolus. Not just a l'il baby PE, but a giant monster that extends into both upper lobes. Unfortunately, this is another often overlooked cause of confusion in the elderly; in retrospect, the only tip-off was the pulse ox. Although not insignificant as a vital sign, it's kind of non-specific; my error, such as it was, was to ignore the low pulse ox with no lung findings. If it's cardiac, or COPD undiagnosed, then there probably should've been wheezes. Yet another near miss. I looked at my chart; not bad, as I would suspect on an admitted pt with a relatively straight-forward course. As always, with these, I was so close and yet so far. The near-misses in my career, unfortunately, are never the ones that I suspect; never see coming. It does make me feel a bit better that she walked around on the floor for four days with her saddle PE and did just fine.

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