pleuritic chest pain

[SCPA]

Here's what walked in the FP office today:

 

Mr X is A 65 yr old CC male who presents today as a work-in complaining of right sided chest pain, which began yesterday afternoon. He states he had ''pleurisy'' years ago and thinks he has another bout of it. The pain is sharp in quality and is aggravated by taking a deep breath. Location is right, anterior lower lung field. He denies cough, hemoptysis, or shortness of breath. No leg swelling or pain or redness. No recent surgery or immobilization or travel.  No active malignancy. No hormonal use. He does have a history of DVT, following surgery a few years ago. 

 

PE was essentially WNL, with special attention to heart and lungs (breath sounds were equal, no sign of consolidation). He was talking comfortably and in NAD. RR normal. EKG was done and showed a RBBB, that was present on an EKG done 6 months ago. EKG was otherwise normal. No s1q3t3. 

 

I calculated his Wells Clinical Prediction Rule for PE score at 1.5 (only + was prior DVT), putting him at Low PE probability (3.6%). Ordered a cbc and d-dimer. No in-house RADS so sent him to the radiology center about 20 minutes away for chest XR.

 

Keeping in mind the 5 p's of plueuritic chest pain in my DD, I decided this was more of a benign pleurisy case and send him on to out pt radiology with Rx for indomethacin. 

 

Instructed him to RTC or ER immediately with any new or increasing chest pain, shortness or breath, coughing/ coughing up blood, etc..

 

Just after the X -ray about 60 minutes later, his wife calls saying the CP has worsened and he is getting SOB. Referred them to the ER, fearing i Just somehow missed PE. 

 

ct scanned in ER and.. BILATERAL PE. 

 

This is my first year in practice and am convinced it's really, really easy to miss things. Any input on what you would have done differently? 

 

[GetMeOuttaThisMess]

1.  I always palpate calves and posterior thighs for tenderness since LE's are most likely source.

2.  One year out, it's hard to trust "your gut" since there isn't much of one yet but if you think about a diagnosis and it can potentially have a bad outcome, I always tell the pt. it'll be much easier to apologize for putting them through a workup and getting an ok from it than apologizing after the fact and wishing you had looked into it a little further.

 

This being said, these diagnoses as well as ischemia can be problematic.  If they've been a duck before, and present like a duck, and you think about their being a duck; exclude the duck.

[Simplify]

So, I have had this chat with a buddy of mine who is also FP and orders Troponin's occasionally.  I feel like if you have a patient that needs to have serious and acute pathology ruled out with lab work  (ACS or in your case PE with d-dimer) that is probably a patient who needs to be evaluated in the ED. 

[UGoLong]

I probably would have ordered the CT on the prior history of a DVT alone, given the symptoms.

 

It's cases like this that will make you suspicious in the future. Don't beat yourself up too much.

[Evolute]

You stated you ordered labs (results?). Was it possible to have the pt wait for the results? Had you had those results prior to the pt leaving the clinic it may have changed your disposition.

 

I agree with the above responses. And would add; Can you r/o the bad stuff ( in this case: PE, ACS, pneumo...among others) in the clinic? If the answer is no, then you may want to consider sending them to the ED in the future. And before all you ED folks jump on me, I work in the ED as well, and get my share of "referrals" from the clinics.  

 

Also, don't beat your self up to badly, but do learn from this. We have all missed things.

[swooshie1]

I'm only about 18 months as a FP provider (new grad),  and when cases like this come in for "Same Day Appts"  (had a similar case the other day),  I try to remind myself of my role.  That is,  if I have ANY suspicion or concern for a dx that could turn badly quickly or is a case that if it did, I cannot manage or monitor in clinic, off they go to the ER.  I don't start labs or workup etc.  Although I know what should be done in a case like this (and the one I had in clinic the other day: e.g., CT, labs, etc), that is not my role and certainly I"m not going to try to coordinate labs / imaging, all of which take time,  when time could be exactly what the patient does NOT have.

[Guest ERCat]

From my perspective since he had that prior history I would've sent him to the ER right away. If PE was at all on my differential I wouldn't want to waste time having the patient do labs on an outpatient basis. However - hindsight is 20/20. We can all say this but if we were in your shoes at the time maybe we would've done the same. I can imagine in primary care it's scary when patients come in with things like chest pain or headache because you don't know if it's something bad (MI, PE, SAH, etc) without having all the diagnostics at your finger tips. And PEs get missed all the time, even when patients present to the ER! The fact that you were thinking about it and worried about it enough shows that you know your stuff - and it seems like your gut was thinking PE for a reason. So next time you're worried about something just send them straight to the ER. That way you save yourself the worry and liability, and potentially save the patient's life. I had a patient come in for something totally unrelated to a PE... She had recent pneumonia and came in complaining of continued cough. She was totally comfy, and she was laughing and cracking jokes with me. No PE symptoms. No pain whatsoever. Only sign was mild tachycardia (like 105). She had a history of DVT and I just had a bad feeling and BAM - saddle PE. Could have easily been missed. Don't get me started on aortic dissections. Don't be hard on yourself - we all have these sorts of things happen no matter how much or how little experience we have. Learn from it and pay yourself on the back for being a part of the crazy world of medicine.

[familygal]

I had a similar case in FP clinic recently with a 48 y/o female c/o pleuritic CP.....Had a recent hx of breast cancer and had just finished several airplane flights before coming in.  But, PE, pulse ox, ECG in office were normal so I did the exact same thing you did....CBC, stat D-DIMER, Chest X-ray and sent her off with instructions that if pain gets worse, go to ER, etc etc.  Well guess what?  At 11 pm (which is STAT in our outpatient world), her D-Dimer came back positive.  So to the ER she went for a CTA.  Which was negative.....

 

I had typically practiced under the theory that someone mentioned above-if you think it's important enough to order the bloodwork (D-dimer, trops), then they should be in the ER where the testing and follow up can be done immediately (BTW  I would never order trops in outpatient setting).  Then,  a few months ago I ordered a stat outpatient CTA on a patient to r/o a PE and got major pushback from insurance (after it was done) since I didn't have a positive D-dimer.  They didn't want to pay for it.  I had to argue with them as to why it was needed without the D-dimer.  So there is that unfortunate but real aspect of practicing medicine.

 

These are good opportunities to look back on what you might have done differently.  In my case with the 48 y/o woman, I should have just ordered the CT scan and saved the patient the time waiting and the cost of the ER visit.  Yes, hindsight is 20/20!  We all have difficult calls like yours.  This will be one you won't forget and will probably save someone else's life in the future because you learned from this case.

[skyfall]

Do you guys have CT scans available where you work? I work in a clinic so we don't have any. CT's have to be scheduled and it won't be about another week until they get it done. 

[mackjacks]

I had a similar case once and tried to order a D dimer. The office didn't have the right color tube top in stock, or it had to be a stat lab pickup on ice or some other reason that the lab/our office wasn't able to accommodate. Not sure if every lab works that way. Just another consideration that makes me more likely to send such pts to the ER for eval. 

[Guest JMPA]

pearl of wisdom, there are several conditions, one being PE, that if suspected or the suspicion crosses the mind, then you should r/o immediately even if you need to write a note to send to er

[chichamorada]

I'm really sorry this happened to your pt.  And I'm so glad to see that you are sharing so as to bring up the discussion.

 

Disclaimer: I am a student :)

but am wondering about a tool called the PERC score (which I know has been critiqued, like many evidence-based H&P systems).

Anyway, it's another level of risk-assessment that is designed to be used only in the setting of a low Well's score.

Each question is worth 1pt, and all answers must be "yes" in order for the likelihood of PE to be <2%

-Age <50

-Pulse <100

-SaO2 >94%

-No unilat leg swelling

-No hemoptysis

-No recent trauma or surgery

-No hx prior DVT or PE

-No hormone use

 

The next step if any of the above are "yes" is an emergent D-dimer (so, refer to the ED), followed by a CT if positive.

Sounds like your patient had at least two PERC points against him.

 

Thoughts anyone?

[8404PA]

We just learned about PE on Wednesday. Thank you for the insight, it's good for me to pair actual cases to the textbook knowledge and see the pieces come together.

 

 

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