Dynamic changes in lead III in a patient with low O2 saturation

An elderly c/o SOB for 2 days. Sat at ~ 80's at room air and increased to 93% at 4LPM. VS 200/100, HR 120 RR 26 afebrile. + Wheezing.

Image 1 - 12 L

Image 2 - Full disclosure on telemetry

Trop was negative, K and Ca was in the normal range, pro-BNP ~ 3000, D-dimer ~ 700. CT showed bilateral pulmonary embolism (PE). 

Image 3 - Composite images of CXR, CTA of the chest and lead I/III

In the real world, the classic changes we expect to see are not there all the time but I think they are there somewhere. The 12L only captures the 10 sec event. During telemetry, the ECG showed dynamic QRST changes: S in I and Q in III and T wave inversion or S1Q3T3 pattern seen in patients with PE.

The patient was started on enoxaparin (bridge) and coumadin. Patient was discharged after a few days.

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