Case Files 12: My Last Breath - SOLVED

A 24 years old lady with a history of HbH thallasemia with post splenectomy 8 years ago on frequent blood transfusion presented to ED with a history of shortness of breath. This patient frequently defaulted treatment and had been non compliant to medication. A month prior, she was admitted into medical ward for decompensated cardiac failure due to cardiomyopathy as a result of iron deposition.

She was seen gasping and was able to speak in few words at best. What was noticeable was her leg swelling was worsening and was tender on palpation. Her jugular venous pulse was strong and reaching her earlobe. She was put on high flow mask and a baseline ECG was recorded as below.

Do you recognize any particular pattern in this 12-lead ECG?
The 12-leads ECG showed a variant of the SI QIII TIII of pulmonary embolism.  Noted that there is right axis deviation with a prominent S wave in lead I (hence SI), and T wave in lead III. (TIII). There is no Q wave though in lead III (QIII). Another distinctive pattern seen was T wave inversion of V1 - V3 as well as P pulmonale (tall tented P waves) seen esp in lead II.

The patient had been having DVT from prolonged immobilization and US Doppler revealed significant DVT over the right lower limb. CT Pulmonary Angiography confirmed the diagnosis with multiple scattered areas of embolization in the lungs. The patient was started on unfractionated heparin infusion and overlapped with warfarin. Her condition improved after 1 week of admission. She was discharged with warfarin, however, knowing that her prognosis is guarded in view of her condition and prolonged non-conpliance to medical therapy.

A week after discharge, the patient was readmitted into ED red zone with another spell of shortness of breath. It was another episode of pulmonary embolism with pulmonary hypertension with biventricular failure and the patient was intubated and admitted into CCU but did not make it through after 2 days there. The parents were counselled of the prognosis and they did not wish for active resuscitation in view of her deteriorating condition thereafter.

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