Pulmonary Embolism in a Patient with Well’s Score of Zero

Abstract

Pulmonary embolism is a condition in which a blood clot blocks a vessel in the lungs. It is a venous thromboembolism that is common and sometimes may prove to be life threatening. Well’s score/Well’s criteria calculates the risks of developing deep vein thrombosis and subsequently pulmonary embolism. Well’s score is based on clinical symptoms of DVT (leg swelling, pain with palpation)(3.0 points each), other diagnosis less likely than pulmonary embolism (3.0 points each), heart rate more than 100 (1.5 points each), immobilization or surgery in the last four weeks (1.5 points each), previous DVT/PE (1.5 points each), hemoptysis (1.0 points), malignancy (1.0 points). If the patient scores 3 or higher there is a high risk of DVT. 1 or 2 score is a moderate risk of DVT. In patients with moderate or higher probability for DVT (cut-off scores of 2), the Well’s score was able to detect patients at risk of developing DVT with a sensitivity of 67% and specificity of 90%. We hereby present a 40-year-old lady with no significant past medical history, who presented to the emergency department with sudden onset of non-radiating right sided chest pain and shortness of breath worsened with walking. Patient denied smoking, recent travels, OCP, recent surgeries, immobilization, previous DVT, pulmonary embolism, hemoptysis, malignancy, miscarriages, lupus. No family history of coagulopathies. Vitals were stable with Blood pressure of 101/60 mmHg, heart rate of 77 beats/minute, afebrile, Respiratory rate of 18, saturating 99% on room air. On examination no leg swelling or tenderness noted, no Intercostal Retraction, no use of accessory muscles, lungs clear to auscultation bilaterally. Venous Doppler study was unremarkable. Chest x ray did not show any cardio-pulmonary disease. The Well’s score came out to be zero with pulmonary embolism very low in the differential. We decided to do CT chest which showed small pulmonary emboli involving bilateral lower lobe sub-segmental pulmonary arteries. D-dimer came out to be 1938. All the rest of the labs and the coagulation factors were within normal limits. We started the patient on lovenox subQ 60 mg Q12 hourly with improvement in the shortness of breath. Patient was discharged on Xarelto. The possibility of DVT should still be considered if the patient presents with shortness of breath with zero Well’s Score.