• Dr. D is a healthy 33 year old marathon runner preparing for a big race in Florida. She sustains a minor calf strain which nags her for 2 weeks before the big day. With airfare and hotels booked, she decides to go ahead with the race despite her injury.
• She powers through the marathon, though finishes with her worst time ever
• 3 weeks after the race she goes for a run and notices that she is dyspneic after only 3 miles (unusual for her)
• Dr. D ignores the exertional dyspnea, chalking it up to a recent URI, and keeps running for the next two weeks, still noting unusual dyspnea after only short (several miles) distances
• Finally presents to PMD and her APN orders an outpt CTPA, which takes 3 days(!) to be preauthorized by insurance
• CTPA demonstrates bilateral lower segmental pulmonary emboli
• Dr. D gets a next day appointment with pulmonology, is started on apixaban, and has a f/u duplex ultrasound demonstrating a left femoral DVT
• She does well and has had no recurrent venous thromboembolism

Key Learning Points:

• Dr. D had no hypoxia, no dyspnea at rest or with usual exertion, no tachycardia, and a Wells score of 0
• The major clues to this diagnosis were:

1. A resting HR of 90. Dr. D's usual resting HR is 50 (marathon runner, remember?). Only ~30% of all comer PE patients are tachycardic on presentation to the ED. Remember many patients may only be relatively tachycardic compared to baseline (like Dr. D) or the effect may be blunted by medications such as beta-blockers.

2. Dyspnea on exertion. Many patients with PE will report no dyspnea at rest, and you should specifically inquire about dyspnea on exertion. Dr. D only experienced dyspnea after running 3 miles, which may seem perfectly reasonable in most patients!

3. Calf pain. This was attributed to a strain, which was reasonable but can be a dangerous assumption in a patient with a possible DVT/PE. Duplex ultrasound or a d-dimer in low risk patients are cheap, easy, non-invasive means to rule out this potential life threatening disease process.

• Clinical suspicion matters and diseases don't follow the book.

• Take care of yourself and eachother! Don't be afraid to reach out for help when you need it, and try to avoid diagnosing yourself or loved ones. We often downplay symptoms in ourselves with the unconscious bias that doctors don't get sick. Physicians become ill just like anyone else, and sometimes it takes an objective evaluation of you as a patient to make the right diagnostic decision and to avoid a potentially tragic outcome.