A 75-year-old with abdominal pain, hypoxia, and weak pulses in the left leg CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 85 • NUMBER 2 FEBRUARY 2018 145 IM BOARD REVIEW Dr. Gornik has disclosed she was a site principal investigator in the Examin- ing Use of Ticagrelor in Peripheral Artery Disease (EUCLID) trial, funded by AstraZeneca. doi:10.3949/ccjm.85a.16069 A 75-year-old man presented to the emer- gency department for evaluation of ab- dominal pain. He had stage 3 chronic obstruc- tive pulmonary disease (COPD), with a forced expiratory volume in 1 second of 33%. ■ PREVIOUS HOSPITALIZATION Aside from his COPD, he had been healthy until 1 month earlier, when he had been hos- pitalized because of shortness of breath and chest pressure with exertion. His troponin T level had been elevated, peaking at 0.117 ng/ mL (reference range 0–0.029). Left heart catheterization had shown no sig- nifcant coronary artery disease. A myocardial bridge of the distal left anterior descending coro- nary artery had been seen, so that the artery ap- peared to be narrowed by 50% to 60% with ven- tricular contraction. But this was not thought to have been the cause of his presentation. On discharge, he required oxygen 4 L/min by nasal cannula. Previously, he had not need- ed supplemental oxygen. ■ CURRENT PRESENTATION The patient described persistent and severe periumbilical abdominal pain during the pre- vious day. It was not associated with eating, and he denied diarrhea, constipation, he- matemesis, hematochezia, bright red blood per rectum, or melena. He continued to de- scribe persistent shortness of breath and pleu- ritic chest pain. His vital signs were as follows: • Heart rate 104 beats per minute • Respiratory rate 16 to 20 breaths per minute • Blood pressure 101–142/62–84 mm Hg • Oxygen saturation 78% on room air. He was placed on oxygen by a Venturi mask, and his oxygen saturation improved to 93%. On examination, his lungs were clear bi- laterally. His abdomen was diffusely tender but without peritoneal signs. His left lower leg was cool to touch, and his left dorsalis pedal and posterior tibial pulses were only weakly pal- pable. His right leg pulses were normal. He de- nied pain in the lower extremities. No jugular venous distention was noted, and cardiac ex- amination was most notable for tachycardia. His laboratory fndings on presentation are shown in Table 1, and his electrocardiogram is shown in Figure 1. ■ WHAT DOES HIS ELECTROCARDIOGRAM SHOW? 1 Which of the following is the most accu- rate description of this patient’s electrocar- diogram? □ Sinus tachycardia, peaked P waves (P pulmonale) in lead II, and T-wave inversions in the right precordial leads □ Sinus tachycardia and left bundle branch block □ Sinus tachycardia and poor R-wave progression □ Sinus tachycardia and ST elevation in the precordial leads Our patient’s electrocardiogram shows sinus tachycardia, P pulmonale, T-wave inversion in the right precordial leads (V 1 –V 3 ), and bi- phasic T waves in lead V 4, , which suggest right ventricular strain. MAYA SERHAL, MD Vascular Medicine Section, Department of Cardiovascular Medicine, Cleveland Clinic NATALIE EVANS, MD, RPVI Vascular Medicine Section, Department of Cardiovascular Medicine, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH HEATHER L. GORNIK, MD, RVT, RPVI Medical Director, Non-Invasive Vascular Laboratory, Vascular Medicine Section, Department of Cardiovas- cular Medicine, Cleveland Clinic; Associate Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH A SELF-TEST ON A CLINICAL CASE GREGORY W. RUTECKI, MD, Section Editor His left leg was cool to touch, with weak pulses; the right leg was normal LEARNING OBJECTIVE: Readers will recognize signs of arterial and venous thromboembolism CREDIT CME