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    When a radiologist reads a chest x-ray, he will look at a number of things, such as whether the lungs are fully inflated or whether there is evidence of pneumonia or tumor. The radiologist will always comment on these findings, regardless of whether it has any bearing on the presumed diagnosis. In this case, the radiologist is reporting two normal findings – No evidence of pneumothorax means that the lungs are properly inflated and no evidence of focal consolidation means that there is no unusual fluid or scarring in the lungs that might be pneumonia. These are normal findings that have no relation to a pulmonary embolus except to rule out other possible causes for the patient’s symptoms. A chest x-ray does not show a pulmonary embolus.

    It hurt to breathe.

    I originally started having chest pain and difficulty breathing in early February a few years ago. Thinking I was getting a nasty infection, I went to the doctor and ended up getting an X-ray, which resulted in a misdiagnosis of pneumonia. They treated me for pneumonia because that’s what they thought I had. I felt amazing for about a week after, and then it flared up again.

    By early March I could no longer sleep on my stomach (I’m a stomach sleeper) or on my side and had to either sleep sitting up or put a pillow under my chest. My entire chest hurt and I had general difficulty breathing. It was pretty frightening because, as I said, I thought it was pneumonia that should have cleared up by then. It was affecting my sleep, any exercise, walking, climbing steps, etc. just about knocked me out, and, again, just breathing was excruciating.

    I went into the doctor’s again to see why the “pneumonia” hadn’t gone away and this time had an MRI. They came back into the room immediately when they got the results and said not to panic but I had a pulmonary embolism in each lung and I had to get to the ER immediately. I ended up spending the night in the ER, getting pain meds, regular EKG readings and jabs of blood thinners. Within a couple of days I was fine, but I was on blood thinners for about a year afterward.

    I had to see a hematologist for a few months after and get regular blood tests until I was in the clear. I was also asked extensive questions about my family history and lifestyle to determine the cause. Verdict: My estrogen-containing birth control pill was the likely culprit — I was the 1 in 1,000 to get a blood clot from their BC pill. I was immediately switched over to a progesterin-only pill and haven’t had an issue since, though I do take preventive steps like wearing compression socks on long flights.

    I wouldn’t wish a pulmonary embolism on my worst enemy. I’m probably lucky it didn’t kill me or cause long-term damage.

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    A pulmonary embolism (PE) is a blood clot in the lung that has dislodged from a vein and travels through the bloodsream. It’s serious and can be life-threatening. But the good news is that if it’s caught early, doctors can treat it. Here’s a look at some of the most common ways they tackle this condition.

    Blood Thinners

    Also called “anticoagulants,” these are the most common treatment for a blood clot in the lung. They serve two key roles: First, they keep the clot from getting any bigger. Second, they keep new clots from forming.

    They don’t dissolve blood clots. Your body normally does that on its own over time.

    The most commonly prescribed blood thinners are warfarin and heparin. Warfarin is a pill and can treat and prevent clots. You get it through a shot or an IV. There are many other blood thinners in pill form, and your doctor will help decide which agent would work best in your situation. Heparin can lower the chances of another clot forming. You get it through a shot or an IV.

    Treatment can begin while you’re in the hospital or even in the ER and you can be discharged the same day. How long you’ll stay and be treated depends on your condition.

    Embolectomy

    In carefully selected cases, this is another emergency treatment your doctor might use. They’ll insert a thin, flexible tube into a vein in your thigh or arm. They’ll continue on to your lung, where they’ll remove the clot or use medicine to dissolve it.

    Other Treatments

    If you can’t take blood thinners, your doctor might use this option to treat your PE:

    Inferior vena cava filter. The inferior vena cava is a large vein that carries blood from the lower body to the heart. Your doctor can put a filter in it to stop clots before they get to your lungs. It won’t stop clots from forming — just from getting to the lungs. This procedure may be needed when blood thinners can’t be used because of a recent surgery, a stroke caused by bleeding, or significant bleeding in another area of the body.

    I assume it would depend on the size and location of the pulmonary embolism.

    The lungs have a special ability to dissolve clots. Many years ago my anatomy and physiology professor taught that we frequently produce small clots that beak off and migrate to the lungs. They are small enough that they do not cause any noticeable impairment, and the lungs just beak them down and the body re-absorbs the components. Larger clots are likely to be noticed, but it may be no more than a slight discomfort in the chest or a cough, or both.

    The more significant pulmonary emboli usually cause a sudden shortness of breath, chest pain, weakness and dizziness, palpitations/arrhythmias accompanied by signs and symptoms of shock.

    The very worst type of pulmonary embolism is called a saddle embolus, which is a large clot that lodges at the bifurcation of the pulmonary artery, blocking blood flow to the lungs, causing rapid collapse and death. It is almost invariably fatal, but I knew a cardiothoracic team that actually saved the life of a patient with a saddle embolus – a one in a million occurrence.

    It was at Loma Linda University Medical Center in California, on Unit 7100, which was the Cardio-Thoracic Surgery ICU. A patient was being brought back after a triple coronary artery bypass. The recovery room nurses, the ICU nurses and the surgical resident had just parked the bed in the room and locked the bed brakes when the patient monitor alarms went off. The surgical resident was brilliant – he diagnosed the problem immediately, grabbed the surgical wire-cutters that were taped to the wall at the head of the bed, cut through the wire sutures holding the sternotomy together, opened the chest, incised the pulmonary artery, scooped out the clot with his finger and flung it against the wall, and held his hand around the pulmonary artery to minimize blood loss and allow blood to flow through the lungs, kneeling on the bed while the team moved the bed back to the OR. The patient lived and went home a week later. It was the most heroic thing I ever heard about. One bright ICU nurse took a picture of the clot sticking on the wall; the clot was about 60 mL volume.

    One of the important things when considering how likely it is that somebody has a pulmonary embolus is this: Is there something else that you know about that would explain the symptoms?

    If a person has chest pain and shortness of breath, and he has a pneumothorax, which causes chest pain and shortness of breath, then it’s less likely that his chest pain and shortness of breath are from a pulmonary embolus. If there’s an infiltrate, he likely has pneumonia, and the same reasoning applies.

    Chances are you’ve made the mistake of looking at the report on your chest x-ray, which was normal. And normal is the usual finding with pulmonary embolus.

    It means that your lungs are fully inflated and it doesn’t seem that you have pneumonia. It doesn’t really mean anything regarding the PE, to be honest.

    That sounds like something you saw on an xray or CT report. Probably a CT if the diagnosis made was pulmonary embolism.

    Those are on there because the radiologist is communicating to the person looking at the study that other problems that may have caused the patient’s symptoms are not seen on the CT scan. It ties into the concept of “differential diagnosis” When a patient comes in with symptoms, like chest pain, a cough, and feeling short of breath, the doctor thinks of possible causes of that constellation of symptoms. They may even put those in when they enter the order for an Xray or CT scan (radiologists greatly prefer getting more information as they don’t usually get to talk to the patient)

    Symptoms: chest pain, cough, dyspnea (feeling short of breath)

    Differential Diagnosis: pneumonia, pneumothorax, pulmonary embolism (PE)

    (the differential might include lots of other things, depending on the patient’s age and other medical problems, as well as the presence of other findings like a fever)

    So the radiologist is saying:

    Pneumonia – unlikely – there is no consolidation

    Pneumothorax – not seen on this study (pneumothorax is air around the lung, commonly known as a “collapsed lung.”)

    Pulmonary embolism – there is a filling defect in (some blood vessel) that looks like a pulmonary embolism. (often on a study like this, they may comment on “heart strain” – that is, is the clot so big it’s causing blood to back up into the heart)

    Final impression: pulmonary embolism

    A pulmonary embolism(PE) is caused by a blood clot that gets stuck in an artery in your lungs. That blockage can damage your lungs and hurt other organs if they don’t get enough oxygen. It’s a serious condition, and recovery can take weeks or months.

    Once you’ve had one, your chances of another go up. But you can do some things to keep your blood flowing and prevent future clots. You’ll also want to watch your legs for signs of a new blood clot. Call your doctor right away if you notice any of these:

    • Swelling
    • Tenderness
    • Warmer-than-normal or red skin

    Diet and Medications

    Drugs called anticoagulants are the first tools doctors reach for if you’ve had a pulmonary embolism. They’re known as “blood thinners” because they make it harder for your blood to clot. They don’t break up a clot, but they keep it from getting bigger as your body dissolves it.

    When you take blood thinners you may need to change what you eat and drink. For example, foods rich in vitamin K which helps your body form blood clots, may change the way blood thinners work. That means you need to try to eat the same amount of leafy green vegetables, fish, liver, and some kinds of vegetable oils that you have been. Do not greatly change how much less or more that you eat of these types of foods.

    Ask your doctor if it’s OK for you to drink alcohol while you take blood thinners.

    You also should talk to your doctor about any other prescription or over-the-counter medicines you take. Some common ones can affect how blood thinners work, too: These include:

    • Cold medicines
    • Pain medicines
    • Sleeping pills

    You can expect to take blood thinners for at least 3 months and possibly much longer. Some people need to take them for life.

    During the acute phase: since most are clots that doesn’t obstruct large pulmonary arterial vessels, it will cause lower oxygen saturation, shortness of breath, if it after a day or so causes a lung infarction (lung tissue due to not getting enough blood dying off) reaches the pleura covering that part of the lung will cause an inflammation, and pain on breathing in deeply, even in 15% of the patients coughing up bloody sputum (haemoptysis), what we primary care about is them not developing more clots and more clots going into the lungs obstructing pulmonary arterial branches, if too much due to blocking the pulmonary arterial circultion will cause a collapse, risking death.

    So doing a D-dimer test (pointing to clots being lysed, since the body tries to get rid of the blood clot), afterward scoring the patient according to the Well’s score, then follow this flow chart

    Imaging studies are calf echography for DVT = deep venous thrombosis, chest x-ray if normal followed by chest CT angiography (iv. contrast needed!).

    If too many/too large a lung emboli, will afterward cause hard to treat pulmonary hypertension, so needs to be treated with intravenous thrombolysis usually using rTPA, otherwise anticoagulation using (low molecular weight) heparine followed by some kind of oral anticoagulation, either old style vitamin K antagonists, or the modern day much more expensive but very convenient novel oral anticoagulants the direct thrombin or direct factor X inhibitors, not to treat the lung emboli, but as stated before to prevent more venous thrombosis from forming from which more pulmonary emboli could be emitted risking death.

    Untreated (uncoagulated) lung emboli patients have a 20% mortality risk.

    This sounds like verbiage from a negative radilogy report for a chest xray. Chest x-rays have little utility in the diagnosis of pulmonary embolus and are usually performed to exclude other diseases or issues when working up a patient with suspected pulmonary embolus.

    A pulmonary emboli is a blood clot becoming loose, travelling to a small pulmonary arterial branch (coming out of the right ventricle of the heart, the low pressure circulation) thus blocking it, the lung tissue behind it not getting any blood (also oxygen) thus dying off: infarction.

    What about the other (bronchial) arterial pulmonary blood supply?

    That, coming out of the left ventricle at high systemic pressues only supplies oxygen to the airways, the bronchi and its branches, but not lung tissue.

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