Medical Doctor

🩺⚠️ CLINICAL CASE CHALLENGE — Can You Solve It?

👨‍⚕️ For Medical Professionals & Students
✍️ By Dr. Nisar Ahmad Ahmadi

📌 CASE PRESENTATION

A 34-year-old male presents to the emergency department with:

Progressive shortness of breath for 3 days
Mild pleuritic chest pain
Dry cough
Episodes of palpitations
Low-grade fever
He has no history of hypertension or diabetes.
No smoking history.

On examination:

BP: 100/65 mmHg
HR: 132/min (irregular)
RR: 30/min
Temp: 37.8°C
SpO₂: 86% on room air

Physical exam reveals:

Elevated JVP
Bilateral basal crackles
Mild right calf tenderness
No pedal edema

📌 ECG FINDINGS

Sinus tachycardia with intermittent atrial fibrillation
S1Q3T3 pattern
T-wave inversion in V1–V4
Incomplete RBBB

📌 LAB RESULTS

D-dimer: markedly elevated
Troponin-I: mildly positive
BNP: elevated

ABG:

pH = 7.48
PaCO₂ = 29 mmHg
PaO₂ = 58 mmHg

📌 ECHOCARDIOGRAPHY

Dilated right ventricle
McConnell sign positive
Estimated pulmonary artery systolic pressure: 58 mmHg
LV function preserved

📌 CT PULMONARY ANGIOGRAPHY

Shows bilateral filling defects in segmental and subsegmental pulmonary arteries.

❓QUESTIONS

1️⃣ What is the most likely diagnosis?
2️⃣ What is the pathophysiologic explanation of the elevated troponin in this patient?
3️⃣ Why can atrial fibrillation occur in this condition?
4️⃣ Which risk stratification category does this patient fall into?
5️⃣ What is the best immediate management?
6️⃣ Would thrombolytic therapy be indicated here? Why or why not?
7️⃣ What is the significance of McConnell sign?
8️⃣ Which underlying thrombophilia should especially be considered in a young patient with unprovoked disease?

💬 Drop your diagnosis and management plan in the comments before seeing the answer tomorrow!