An Elderly Woman With Dyspnea.

A woman in her 70s with a history of hypertension, hyperlipidemia, and venous thromboembolismpresented to the hospital with 2months of progressivelyworsening dyspnea onexertion.Hermedical historywas significant for a singleepisodeof lower-extremitydeep venous thrombosis during a prior hospitalization, complicated by multiple subsegmental pulmonary emboli. At that time, she underwent inferior vena cava filter placement, followedby initiation of anticoagulation therapy. Her current medications includedmetoprolol tartrate, simvastatin, andwarfarinsodium. She denied any substantial tobacco or alcohol use, and her family history was negative for venous thromboembolicdisease.Her initial physical examinationhadunremarkable results,with laboratory evaluationof prothrombin time significant for an international normalized ratio of 2.8. Computed tomography (CT) of the chest revealed a large filling defect within the main pulmonary artery, flattening of the interventricular septum, and multiple pulmonarynodules.Bedside transthoracicechocardiographydemonstratedevidenceof severely increased right ventricular systolic pressure, with moderate right ventricular dilation. She was referred for urgent pharmacomechanical interventions, including catheterdirectedembolectomyandthrombolysis, forapresumeddiagnosisofsubmassivepulmonary embolism. Following the procedure, she experienced no substantial clinical or radiographic improvement. She underwent a repeated CT scan of the chest (Figure). Quiz at jamaoncology.com A B