SESSION TITLE: Pulmonary Vascular Disease Case PostersSESSION TYPE: Case Report PostersPRESENTED ON: 10/17/2022 12:15 pm - 01:15 pmINTRODUCTION: A pulmonary embolism (PE) represents a potentially life-threatening condition that may require immediate intervention. While many physicians recognize the classic presentation of tachycardia, tachypnea and chest pain, these are only present in 24-54% of patients and even fewer have all three (1,2). Therefore, it is important to maintain a high index of suspicion and recognize atypical presentations. Here we report a case of a patient presenting with severe epigastric abdominal pain that was found to have a PE.CASE PRESENTATION: A 56-year-old man with a history of COPD, HTN, previous MI and T2DM presented to the emergency department with sudden onset epigastric abdominal pain. His vital signs were notable for a respiratory rate of 28, heart rate of 120 and oxygen saturation of 98% on room air. His physical exam revealed epigastric tenderness. Labs revealed a WBC of 15, normal troponins and a lactate of 2.7. His venous blood gas was normal. His ECG was remarkable only for sinus tachycardia. His chest radiograph was unremarkable. A CT angiography of the abdomen/pelvis was obtained due to concern for bowel ischemia and was unremarkable. Due to the patient's tachycardia and tachypnea, a CT angiography of the chest was obtained and demonstrated a PE involving the right lateral basilar segmental artery. He was treated with oral anticoagulation.DISCUSSION: Many efforts have been made to generate a scoring system to guide the diagnosis of PE. The modified Wells criteria, PE rule out criteria (PERC) and revised Geneva score are widely used (3). A significant limitation of these systems is that a physician must first consider the diagnosis of PE before applying them. Therefore, while these tools attempt to limit the use of pure clinical gestalt in determining which patients to scan or obtain a d-dimer on, the first step in the diagnostic pathway is clinical suspicion. An additional limitation is discrepancy between scores. For example, our patient's modified Wells score was 1.5, placing him in the low-risk group (< 3% incidence of PE). On the other hand, his PERC score was 1, indicating PE could not be ruled out and his revised Geneva score was 5, indicating moderate-risk (20-30% incidence of PE).CONCLUSIONS: A PE is known as "the great masquerader” due to its ability to mimic a variety of diagnoses. While risk stratification tools such as the modified Wells score, PERC and revised Geneva score are helpful, it should be recognized that they are imperfect. In our patient, the unexplained tachypnea and tachycardia prompted concern for PE despite his low-risk Wells score. His abdominal pain was a red herring, but is an important reminder of the variability of symptoms that patients with a PE can present with. Ultimately, if a patient has unexplained vital signs derangements that are consistent with PE without other plausible explanations, PE should be considered.Reference #1: Stein, Paul D et al. "Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II.” The American journal of medicine vol. 120,10 (2007): 871-9. doi:10.1016/j.amjmed.2007.03.024Reference #2: Pollack, Charles V et al. "Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry).” Journal of the American College of Cardiology vol. 57,6 (2011): 700-6. doi:10.1016/j.jacc.2010.05.071Reference #3: Tarbox, Abigail K, and Mamta Swaroop. "Pulmonary embolism.” International journal of critical illness and injury science vol. 3,1 (2013): 69-72. doi:10.4103/2229-5151.109427DISCLOSURES: No relevant relationships by Loor AlshawaNo relevant relationships by Andrew Rudnick SESSION TITLE: Pulmonary Vascular Disease Case Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: A pulmonary embolism (PE) represents a potentially life-threatening condition that may require immediate intervention. While many physicians recognize the classic presentation of tachycardia, tachypnea and chest pain, these are only present in 24-54% of patients and even fewer have all three (1,2). Therefore, it is important to maintain a high index of suspicion and recognize atypical presentations. Here we report a case of a patient presenting with severe epigastric abdominal pain that was found to have a PE. CASE PRESENTATION: A 56-year-old man with a history of COPD, HTN, previous MI and T2DM presented to the emergency department with sudden onset epigastric abdominal pain. His vital signs were notable for a respiratory rate of 28, heart rate of 120 and oxygen saturation of 98% on room air. His physical exam revealed epigastric tenderness. Labs revealed a WBC of 15, normal troponins and a lactate of 2.7. His venous blood gas was normal. His ECG was remarkable only for sinus tachycardia. His chest radiograph was unremarkable. A CT angiography of the abdomen/pelvis was obtained due to concern for bowel ischemia and was unremarkable. Due to the patient's tachycardia and tachypnea, a CT angiography of the chest was obtained and demonstrated a PE involving the right lateral basilar segmental artery. He was treated with oral anticoagulation. DISCUSSION: Many efforts have been made to generate a scoring system to guide the diagnosis of PE. The modified Wells criteria, PE rule out criteria (PERC) and revised Geneva score are widely used (3). A significant limitation of these systems is that a physician must first consider the diagnosis of PE before applying them. Therefore, while these tools attempt to limit the use of pure clinical gestalt in determining which patients to scan or obtain a d-dimer on, the first step in the diagnostic pathway is clinical suspicion. An additional limitation is discrepancy between scores. For example, our patient's modified Wells score was 1.5, placing him in the low-risk group (< 3% incidence of PE). On the other hand, his PERC score was 1, indicating PE could not be ruled out and his revised Geneva score was 5, indicating moderate-risk (20-30% incidence of PE). CONCLUSIONS: A PE is known as "the great masquerader” due to its ability to mimic a variety of diagnoses. While risk stratification tools such as the modified Wells score, PERC and revised Geneva score are helpful, it should be recognized that they are imperfect. In our patient, the unexplained tachypnea and tachycardia prompted concern for PE despite his low-risk Wells score. His abdominal pain was a red herring, but is an important reminder of the variability of symptoms that patients with a PE can present with. Ultimately, if a patient has unexplained vital signs derangements that are consistent with PE without other plausible explanations, PE should be considered. Reference #1: Stein, Paul D et al. "Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II.” The American journal of medicine vol. 120,10 (2007): 871-9. doi:10.1016/j.amjmed.2007.03.024 Reference #2: Pollack, Charles V et al. "Clinical characteristics, management, and outcomes of patients diagnosed with acute pulmonary embolism in the emergency department: initial report of EMPEROR (Multicenter Emergency Medicine Pulmonary Embolism in the Real World Registry).” Journal of the American College of Cardiology vol. 57,6 (2011): 700-6. doi:10.1016/j.jacc.2010.05.071 Reference #3: Tarbox, Abigail K, and Mamta Swaroop. "Pulmonary embolism.” International journal of critical illness and injury science vol. 3,1 (2013): 69-72. doi:10.4103/2229-5151.109427 DISCLOSURES: No relevant relationships by Loor Alshawa No relevant relationships by Andrew Rudnick