Hi doctor,I am a physician doing postgraduation in histopathology. I am a 29 year old female. My history is of 4 years old. I had two episodes of syncope with a period of two months followed by unilateral (right) tinnitus which disappeared on pressing the right carotid, which I totally ignored. A year later, I was diagnosed to have pulmonary embolism on the right segmental branch with the symptoms of hemoptysis, chest dyspnea, and an episode of syncope. My initial tests were performed from thrombophilia profile to every other investigation. The homocysteine level was 22 while thrombophilia profile showed protein S and factor 5 decrease. I was put on Rivaroxaban after acute treatment. I took Xeralto for a year, and then I quit.After 1.5 years from the first episode, I again developed symptoms and this time the CT angiogram showed decrease in right segmental pulmonary embolism and new left subsegmental multiple thrombi. I got my investigation repeated, and the thrombophilia profile was normal. All other examinations were normal as well. I have again put on Rivaroxaban 20 mg od after acute treatment. I had no DVT, and my echo and carotid doppler were normal. There is no past history of surgery, and I am not married neither sexually active.Last week, I again had chest pain with dyspnea. The CT angiogram showed left subsegmental thrombus with basal consolidation and pleural effusion. Now, I am switched off to Warfarin. Kindly help me regarding this to reach the diagnosis. As it is recurrent idiopathic pulmonary embolism, what should I do now?
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