Anxiety With Panic Attacks - Lacrosse

HISTORY: A 19 yo NCAA Div I Women’s Lacrosse athlete presented with a week of rib pain and anxiety. Symptoms started at practice during sprints and included intermittent SOB worse when supine, dyspnea on exertion, substernal sharp chest pain, fatigue, nausea, tachycardia, and weakness. She denied symptom worsening but was unable to practice. She is on escitalopram and hydroxyzine hcl for GAD w/panic attacks and MDD. NuvaRing for contraception. No other sx. No hx of DVT, PE, leg swelling, recent travel, or tobacco use. PHYSICAL EXAMINATION: Pt in acute distress. Pulse ox 95. Lungs clear to auscultation b/l. Heart RRR, no murmurs. TTP LUQ and left lower ribs. No LE edema. AAOx4. Appropriate mood, affect, speech, thought process, and judgement. No SI. Over the next 12 hrs SOB and chest pain worsened. She had hemoptysis/hematemesis w/pallor, central cyanosis, tachypneic, increased WOB, tachycardia 140 s, and pulse ox 50. DIFFERENTIAL DIAGNOSIS: 1. Generalized anxiety disorder w/panic attacks2. Intercostal muscle strain3. Acute pulmonary embolism TEST AND RESULTS: CRP 160.47, BNP 550, WBC 13.22, Ddimer 7.89, Trop 219, Lactate 4.9EKG: Sinus tach. Right axis deviation.CXR: Trace left pleural effusion.Echo: Abnormal septal wall motion d/t RV pressure overload. RV enlarged w/reduced systolic function. Segmental wall motion abnormality, McConnell’s sign. RVSP 62 mmHg.CTPE: Extensive b/l distal central pulmonary arteries and multilobar acute pulmonary embolism w/RV strain. Venous runoff to pelvis w/femoral iliac vein compression (May Thurner syndrome). FINAL WORKING DIAGNOSIS: Acute Sub-massive Pulmonary Embolism TREATMENT AND OUTCOMES: 1. Gave tPA. Admitted to CICU w/Heparin gtt and heated high flow oxygenation.2. Discharged on room air after 1 wk. NuvaRing discontinued. Eliquis started.3. Started walking exercise 1 wk post discharge. By 3 mo returned to non-contact (d/t anticoagulation) practice. Dyspnea w/sprints, otherwise no sx. Repeat Echo normal RV size/function, no PH. Bubble study w/o PFO. VQ scan b/l mismatches and perfusion defects. No clotting disorders per hematology.4. At 6 mo VQ scan w/contd perfusion defects. Anticoagulation and restriction from contact sport contd. Pt asymptomatic.5. Progression to contact sport limited by residual VQ mismatch w/concern for chronic PE requiring anticoagulation.