PE

Location: Emergency room

Vitals: BP: 90/60 mmHg; PR: 112/min, regular; Temperature is 36.7C(98F); RR: 34/min.
C.C: Shortness of breath and chest pain.
HPI:A 65-year-old white female, with a past medical history of ovarian carcinoma treated with chemotherapy, presents to the emergency room with the sudden onset of severe shortness of breath associated with right-sided chest pain.  The patient reports that while watching the baseball game she suddenly noticed severe shortness of breath. The pain is constant, 7-8/10 in severity, increases with deep breaths, and non-radiating. She is nauseated IV access, stat
1.Pulse oximetry, stat 83% on room air and 94% on six liters of oxygen.
2.Oxygen inhalation, continuous
3.Elevate the patient head
4.Cardiac monitoring, continuous
5.Aspirin, sublingual, one dose
6.Sublingual nitroglycerine is not indicated in this patient, as his BP is borderline low.
7.physical exam:
8.Patient is still having shortness of breath.
9.12 lead EKG, stat new onset right bundle branch black.
10.Portable chest X-ray, PA view, stat within normal limits.
11.CK-MB, stat
12.Troponin I, stat normal limits
13.ABG, stat PO2 of 60, PCO2 of 34, and PH of 7.50.
14.PTT, stat, one timePTT is 30
15.PT/INR, stat, one timePT is 12.5 and the INR is 0.9
16.CBC with diff, stat Mild leukocytosis but no bandemia
17.Basic metabolic panel, stat
18.Normal saline, IV, continuous
19.FOBT (Fecal Occult Blood Testing), stat (Result-Negative)
20. Heparin, IV, continuous
21.V/Q scan, stat Intermediate to high
22.D-dimer, stat elevated.
23.Patient is slightly better on oxygen
24.Admit the patient to ICU
25.Continue cardiac monitoring (telemetry)
26. Pulse oximetry, every 2 hours
27.Maintain oxygen saturations >90-92% with high flow oxygen (100% Non-rebreather mask)
28.NPO
29.Vitals: ICU routine
30.Complete bed rest
31.Urine output
32.CBC with diff in 24-hours
33.PTT for every 6 hours (adjust the heparin drip to a goal aPTT of 55-70)
34. *Perform brief history and physical exam for every 2 to 4 hours until you see clinical improvement.
35.Next day,
36.Consider weaning oxygen
37.Stop IV fluids if the BP is stable
38.Start regular diet
39.Change vitals to Q 8 hours
40.D/C continuous cardiac monitoring
41.Start Coumadin (warfarin), once daily (for a female of reproductive age always rule out pregnancy before you give warfarin i.e. order a pregnancy test).
42.Daily PTT/PT/INR
43.Check the platelet count and Hb (CBC with diff), as heparin is associated with thrombocytopenia and bleeding.
44.Discharge the patient:
45.Once the INR is above 2, plan for discharge (goal is 2-3)
46.D/C heparin on 4th or 5th day
47.Anticoagulation teaching
48.Patient counseling
49.Follow-up in 2 days for PT/INR checked. 
50.Continue warfarin for 12-months and monitor INR twice weekly.  During follow up look for any sites of bleeding. (In general, menstruation is not a contraindication of warfarin. If patient wants to become pregnant D/C warfarin and start heparin.)
51.No smoking