ER Case Study - An Unique Case of Reproducible Chest Pain

[karebear12892]

Hi everyone! I'm about five months away from graduation and I've been browsing through case study posts for awhile now, but this is my first time posting one of my own, so please be gentle.

50 y/o AA male presented to rural ER via EMS w/ complaints of chest pain. EtOH on board. Given ASA and 1 NTG spray en route without relief. 

VS: HR 108, BP 110/65, RR 14, T 98.5, SpO2 99%

Onset: "either 3 or 12 weeks ago" (intoxicated, no family present). Upon being asked what prompted him to seek emergency medical care today, he stated the pain had been significantly worse since he woke up this morning (saw him around 19:30). 

Unable to sensibly describe the quality of his pain

Timing: constant 

Radiation: neck, jaw, both arms, back

Aggravating Factors: deep inhalation, coughing, sneezing, decubitus positioning on either side

Alleviating Factors: none, no medications at any point since onset of symptoms prior to EMS arrival

Past medical history: none reported, no PCP, no daily medications

Surgical history: non-contributory

Social history: drinks liquor daily, freely admitted to consuming 1 pint of vodka earlier that day, smokes cigarettes daily, no illicit drug use reported 

ROS negative except for chest pain - no associated symptoms. 

PE (positive findings only): Clinically intoxicated, tearful. Appears thin. Tachycardic. Tenderness to palpation along sternum and anterior chest wall bilaterally. Pain is also reproducible with deep inhalation on lung exam. 

What's on your differential? What tests would you order? Ready, set, go! 

[UGoLong]

MI (doubtful) vs pancreatitis vs costochondritis vs aortic aneurysm vs liver issue.

12 lead, serial enzymes, LFT, anylase/lipase, cxr, really good physical exam.


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[karebear12892]

All good thoughts, UGoLong. Anyone else? I'll post more info in 24 hours. 

[Doppio_Espresso]

idk, I'm not a student yet so I most likely don't know what I'm talking about lol, but just tossing in GERD or sickle cell crisis (although, pt doesn't know if he has hx of sickle cell.. maybe toss in CBC???). 

Edited July 9, 2018 by Doppio_Espresso

[EMEDPA]

22 hours ago, UGoLong said:

MI (doubtful) vs pancreatitis vs costochondritis vs aortic aneurysm vs liver issue.

12 lead, serial enzymes, LFT, anylase/lipase, cxr, really good physical exam.


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vs trauma to include rib fxs, contusions, pneumo, etc. he was drunk. maybe he was in a bar fight.

esophageal spasm would make the list as well as the GI causes listed above + ulcer, gastritis. Could also have run of the mill aspiration pneumonia or shingles(easy to miss if you don't actually look at the chest).

tachycardic, so need to at least consider and risk stratify for PE. aortic dissection and esophageal rupture unlikely.

[Guest JMPA]

Poor cardiopulmonary history. Certainly would need to do testing do to lack of good history. From what is stated it describes pleuritic chest pain. Should consider pleuritis and pericarditis in differential. Are the vitals pre or post nitro? GI is definitely in my differential. Consider mets.

[UGoLong]

Chest pain has a huge differential. Lots of physical examination to be done, along with assessing vitals, before one zooms off into all the cosmic choices.


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[LT_Oneal_PAC]

CBC (terrible screening test, but it is a routine lab in our world, could also reveal low Hgb in the case of a leaking dissection) 

BMP (standard to eval electrolytes and kidney function which will help with interpretation of troponin)

Troponin

EKG: Looking for STEMI and STEMI equivalents(always) PR depression (pericarditis, but there are other stages with other findings)

Eval Well's. He can't be PERC'ed

Ethanol level. He may not actually be drunk.

CXR looking for widened mediatsinum, mediastinal air in boerhaave, calcification sign, PNA, westermark sign for PE, pleural effusion, water bottle sign/oreo cookie sign

Physical exam to include BP bilateral arms, unilateral leg swelling, abdomen for pulsatile mass, JVD, feel chest for rib step off/crepitus, check for chest symmetry and subcutaneous air (PTX or boerhaave). Check a weight and look and see if he's been there before for previous weight gain or loss.

He's thin and thus US would be easy. Cardiac US to eval for right heart strain caused by massive PE, pericardial effusion in subxiphoid, eval for obvious LV hypokinesis, and should be able to see aorta posteriorly in thin male through parasternal view. Alternatively look in epigastric and track it back up looking for dilation or intimal flap.

Lung US to identify PTX quickly and with more sensitivity than CXR

One could argue LFT to eval ALP and bilirubin in case of cholangitis causing his confusion and not alcohol, as well as lipase for pancreatitis, but I have low pretest probability of this giving my answer and likely would not order. Not wrong though.

For my lab order "stored blue tube" incase I want to add a PT/PTT if he needs to go to cath lab emergently or need to start heparin.

Consider d-dimer for PE.

To condense the above: CBC, BMP, troponin, CXR, EKG Ethanol, US, good physical, well's and heartscore calculation. May move to d-dimer and CT or CTA chest depending. 

DDX: Higher- Trauma with possible rib fracture or pulmonary contusion, boerhaave, dissection, aneurysm, MI, PTX, esophageal spasm, PNA (possible aspiration), pneumonitis, sepsis, bilateral shingles (hey, you want a full ddx or not?), costochondritis, PE, pericardial effusion, hiatal hernia, GERD

Edited to add: Oh, maybe look at his shoulders. Could be stopped drinking for bit and had ETOH withdrawal seizure. You laugh but I saw a case where this was missed, bilateral anterior shoulder dislocations.

 

Edited July 10, 2018 by LT_Oneal_PAC

[karebear12892]

Great dialogue! This is an excellent list of differentials! 

JMPA, the vital signs were post-NTG. 

EMEDPA, I've seen that mistake, too.  Especially with flank pain. In this case, no rash was present. 

Doppio Espresso, good for you for taking a guess! GERD is certainly a possibility....generally more of a diagnosis of exclusion in the ER. Sickle cell crisis is also a good thought, although it would be exceedingly rare (never say never, right?) for this to present initially at age 50. 

LT O'Neal, I would have loved to ultrasound him (especially once we diagnosed him), but unfortunately none of the ER providers there are comfortable with POCUS.  Not even sure this ER has an US machine, come to think of it. I hadn't thought about bilateral shoulder dislocation - will definitely have to keep that one in mind next time I see a similar presentation. Thanks! 

EKG: Sinus tachycardia, HR 109, RBBB, and Q-waves present in lead I and II. Unchanged from prior tracing in February 2018. When asked again about CV risk factors and prior CV events, he adamantly denied everything except smoking (granted, he was intoxicated and does not see a PCP). 

CBC, CMP, magnesium, PT/INR, PTT, and lipase normal. Troponin was 0.000. Did not obtain an amylase level. 

Chest x-ray (1 view, portable): no acute process, per radiologist. Also reviewed by attending MD, PA, and myself without significant findings. 

Ethanol level: 345. Given banana bag. 

I gave him (and attending agreed) a HEART score of 3 and a Wells' PE score of 1.5 (as LT O'Neal stated, he is not a candidate for PERC). 

D-Dimer: 2.14 (normal for us is < 0.5). CTA per PE protocol obtained. 

Any guesses as to what it showed? Hint: there were two major abnormalities, both warranting admission. Will post results in 24 hours.  

Edited July 10, 2018 by karebear12892

[LT_Oneal_PAC]

Hmm... Could be PE or dissection. I suppose I'll go with dissection. Lots of things here that go with both. I dunno. Maybe he does have both. 

Just woke up from a well deserved nap and thinking more clearly. PE with lung Mets is high on my diff.

Edited July 11, 2018 by LT_Oneal_PAC

[SERENITY NOW]

Nice case!  Top ddx: trauma/ptx, PE, boerhaves, effusion/tamponade -- CT will find all of them!  What did the tunnel of truth find?!

[EMEDPA]

boerhaves?

[karebear12892]

Great job, everyone! 

CTA Chest: Moderate size pulmonary embolism in the right lung and multiple lytic lesions throughout the sternum, ribcage, and cervical/thoracic spine. No lung mass present. Metastatic disease until proven otherwise, per radiologist. 

Patient was started on Lovenox 1 mg/kg and admitted to hospitalist. I've since lost track of him but I wouldn't be surprised if he was transferred to one of the larger medical centers down the road, as our hospital has no oncologists on staff. 

When I re-evaluated the patient, his tachycardia had resolved. I examined him again specifically looking for enlarged lymph nodes, clubbing of the digits, lower extremities for evidence of DVT, and bony tenderness elsewhere. All of this was negative. Did not perform DRE (wasn't going to change our plan at this point) but asked him about GU symptoms (if the mets did not come from the lung, prostate was my next thought), recent weight loss, fevers, hemoptysis, pathological fractures, nocturnal pain....he denied everything. Could still be multiple myeloma although I would have expected to see some evidence of this in his labs (anemia, renal failure). No further work-up done in the ER -- as my attending loves to say, "we'd hate for the hospitalists to be bored."

A couple of learning points I took away from this case:

1. This patient was intoxicated and complaining of chronic, easily reproducible, atypical chest pain w/ HEART score of 3. He had every reason to fall through the cracks and not be taken seriously. This case reminded me just how many causes of chest pain need to be excluded before comfortably diagnosing a patient with costochondritis and discharging them home. In this particular patient, the chances of him actually complying with PCP follow-up were slim, so who knows when he would have been diagnosed if we hadn't worked him up as extensively as we did.

2. My gestalt to order a D-dimer was based on his tachycardia, the reproducible nature of his chest pain, his smoking, and his unreliable history. His Wells score corresponded with my decision, although it only accounted for one of these four reasons. He was not on any cardiac meds - if his heart rate had been 99 instead of 108, would we have ended up scanning him? Algorithms aren't perfect - in this case, it did support our medical decision making, but sometimes it's just one piece of the puzzle and you've got to consider the big picture. 

3. There were so many significant findings on the CT, yet the CXR was completely normal. Both read by the same radiologist. This was a reminder that a normal chest x-ray does not necessarily mean you've ruled out all serious causes of chest pain, despite how often we order it in the ER. One of my preceptors once said that "all patients with pleuritic chest pain and a normal CXR have a PE until proven otherwise." Certainly applicable in this case.  

If you have any other takeaways from this case, please feel free to share. Thank you everyone for your participation!

Edited July 12, 2018 by karebear12892

[EMEDPA]

Remember heart score is more specific for ACS than PE. I used it yesterday to force a transfer and cath. Guy had no hx, but a great story, bad ischemic ekg, and neg trop with multiple risk factors, giving him a score of 6.

[karebear12892]

24 minutes ago, EMEDPA said:

Remember heart score is more specific for ACS than PE.

Absolutely. I only included that to illustrate that it is easy for providers/students to fall into the trap of non-cardiac chest pain = non-emergent chest pain. Good call - hope your patient did well! 

[LT_Oneal_PAC]

i would have d-dimer him probably even without the tachycardia. Poor history, smoking, poor pcp follow up. Chest pain going to the back, this guy would have made me worry about dissection, though I may have been less worried with a good cardiac US, but I still would have had low threshold to do CTA.

Something on to remember in these alcoholics too is holiday heart and alcoholic heart failure. We don’t understand why it happens, but I’ve seen it.