Case Study: (12 pts)

Ms. V.A. is a 30-year-old woman who presents to the hospital emergency room following 90 minutes of chest pain, stating, "I have severe chest pain and I can't seem to catch my breath. I think that I may be having a heart attack." She describes the severity of her pain as 8 on a scale of 10. An hour and a half ago, she developed sharp and constant right-sided chest pain and right-sided mid-back pain. The pain became worse when she attempted to lie down or take a deep breath and improved a little when she sat down. She also has had difficulty breathing. She denies any fever, chills, or coughing up blood. She reports that she just returned home 36 hours ago following a 13-hour flight from Tokyo.

Past medical history shows:
- Migraines with aura since age 13
- Mild endometriosis for 5 years
- Positive for Protein S deficiency
- One episode of deep vein thrombosis (DVT) 2 years ago, treated with warfarin (Coumadin) for 1 year
- Acute sinusitis

Family history:
- Father has hypertension
- Mother died from metastatic cervical cancer at age 49
- No family history of venous thromboembolic disease

Social history:
- She is a 12-pack a year smoker and currently smokes 1 pack per day
- She is a business executive with an active travel schedule
- She claims no alcohol or IV drug use

Physical exam:
- Both right and left lower extremities show abnormal venous narrowing consistent with bilateral DVT.

Questions:
a. What is the most likely cause of this woman's shortness of breath? What led you to your decision? (2 pts)

b. Is this woman having a heart attack? What leads you to this decision? (2 pts)

c. What are 3 possible risk factors of this patient for a pulmonary embolism? (3 pts)

d. What is the significance of an elevated D-dimer and BNP and a decreased fibrinogen? Describe each. (3 pts)

e. Research Protein S deficiency. How does a deficiency in Protein S contribute to clot formation? (1 pt)

f. How does the fact that this patient just returned from a long flight contribute to the formation of clots, DVTs, and possible emboli? (1 pt)