A 33-year-old female, P.H., presented on Saturday morning with a two-day history of excruciating, left side, midthoracic to upper lumbar back pain.  She complained that she had more discomfort when lying down.

She denied any recent known injury, but affirmed a previous history of back pain. She was certain that she just needed some cyclobenzaprine and some stronger nonsteroidal anti-inflammatory drugs.  P.H. was well known within the practice. She was a registered nurse who worked in the ED and lived in the community.

Her vital signs were all within normal limits, and the focused musculoskeletal exam was essentially unremarkable, except that she was extremely restless and agitated.  She bounced around the room clinging to her left side, crouching in a chair but refusing to lie down.  In a few seconds, she would jump up and try to find another comfortable position. Further exam of her heart was unremarkable, and breath sounds were equal bilaterally except for a subtle coarseness in the base of the left lung.  The oxygen saturation was 95%.  She smoked a pack of cigarettes per day. Interestingly, she was three months post complete hysterectomy and had already been placed on hormone replacement therapy.   

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Treatment options included a shot of ketorolac, but she refused.  As I spent more time with her, I began to consider that her agitation could be due to withdrawal, but that didn’t fit either.  I was confident drugs were not in her life. Her presentation was simply odd.  It made me uncomfortable and took me back to my days as a RN in the medical ICU and the ED, when healthy young individuals with acute respiratory distress syndrome presented only with the symptom of restlessness. It was déjà vu.

P.H. did not want the lab work.  We actually had a professional argument about the labs ordered.  As it turned out, she was needle phobic when it came to someone sticking her instead of vice versa.  I shared my concern about her restlessness and told her that I wanted to draw a D-dimer.  She laughed. I told her I would eat crow if I was wrong, but that her restlessness was very concerning. 

She was discharged with her requested medications and instructions to stay by the phone, as I would call her with the results.  The hospital obliged my STAT request, and within two hours the critical values of a D-dimer 10 times that of a normal test were called to my home. Although I was not on call, I had told my MD that I would follow this case through. 

P.H. was taken to the hospital by her husband, seen in the ED and diagnosed with two large pulmonary emboli in her left base. She spent the next five days in medical ICU.

I saw P.H. at the local grocery store about three weeks later.  We laughed, and then we cried.  This Shakespeare quote sums it up best, “How art thou out of breath, when thou hast breath. To say to me that thou art out of breath?”

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