S1Q3T3, pulmonary embolism diagnosed primarily from ECG results in a patient with dysphagia and low Wells score

A man in his late 60s with previous chronic obstructive pulmonary disease and insulin-dependent diabetes presented with a 10-day history of shortness of breath and cough and progressive breathlessness accompanied with significant weight loss over 6 months. On examination, it revealed poor swallow, dysphagia for both solid foods and liquids and not taking any regular medications due to problems with swallowing. On further history taking, the patient had a positive first relative family history for oesophageal cancer and lung cancer on the paternal side. Patient acutely desaturated and increased New Early Warning Score during the evening on call, and prominent S1Q3T3 was seen on ECG, which prompted immediate anticoagulation and CT pulmonary angiogram confirmed an acute thrombus with significant right heart strain. This case highlights the importance and sometimes neglected signs of right heart strain and elusive recognition of the S1Q3T3 phenomenon in acutely unwell and deteriorating patients to aid in the diagnosis of pulmonary embolism.