Student Case #3

[deborah212]

23 yo African American female presents to the ED with a complaint of "my chest hurts."

 

Vitals: T 98.4 P 92 BP 118/62 RR 18 O2 Sat 89% on RA, 100% on 4L

 

What do you want to ask her?

[SCHMITTIE120]

start with the PROS (pertinent review of systems): Cardiac, GI,

 

make sure you OPQRST the pain too and include any associated symptoms.

I am only in my first semester though, so I do not know too much

[kargiver]

Can I play??? :)

[TraumawannabPAs]

Agreed, include questions about trauma, PMHx, meds, allergies?? Aside from asking questions, what does she look like

(sick/ not sick)?

start with the PROS (pertinent review of systems): Cardiac, GI,

 

make sure you OPQRST the pain too and include any associated symptoms.

I am only in my first semester though, so I do not know too much

[TraumawannabPAs]

Not fair.. lol :)

Can I play??? :)

[deborah212]

Can I play???

lol. No... but I'd love to share war stories with you soon! :)

start with the PROS (pertinent review of systems): Cardiac, GI,

make sure you OPQRST the pain too and include any associated symptoms.

I am only in my first semester though, so I do not know too much

Good. What kind of questions would you ask the patient to get the OPRST? What are the pertinent ROS questions?

Agreed, include questions about trauma, PMHx, meds, allergies?? Aside from asking questions, what does she look like

(sick/ not sick)?

Your 6th "sickness" sense is tingling vibrantly.

 

Patient denies recent trauma.

 

PMHx:

SCD (sickle cell disease), SS

 

Meds:

Hydroxyurea 1000 mg qd, per heme regimen

Folic Acid 1 mg qd

Dilaudid 4mg po q4hrs prn pain

Yaz (OCP) 1 tab qd x 24 days then inert tabs x4 days

 

 

Allergies:

NKDA

[sailordeac]

pulm ROS, family hx, social hx

 

describe the nature of the pain, when it started, was she doing anything special when it started, rate on scale 1/10, where it's located, does it radiate, anything make it feel better or worse, ever had anything like this before

[acozadd]

With the sickle disease and OCP I'd run a D-dimer and consider CT scan PE protocol. Don't know enough about history yet but that would be bumped to the top of my differential list.

[chiaroscuro27]

Ok here goes!

 

Onset of chest pain, what setting, what is the quality of the pain, what is the pain on a scale from 0 to 10, does the pain radiate, any additional symptoms related to this chest pain, has the pt. taken anything for this pain and has it helped, and does anything make the pain worse. Is the patient pregnant as far as she knows? Last normal menstrual cycle?

 

I would ask ROS questions pertaining to Cardiac, GI, and Pulm systems: palpitations, SOB when lying flat, leg swelling, wheezing, any coughing with sputum production (and if so what was the amount, color, odor, and consistency) hemoptysis, abdominal pain, hematemesis, reflux, diarrhea, nausea, vomiting.

 

I'll stop there. Can't wait for the update!

[deborah212]

describe the nature of the pain, when it started, was she doing anything special when it started, rate on scale 1/10, where it's located, does it radiate, anything make it feel better or worse, ever had anything like this before

Great. Patient felt fine until yesterday when she began experiencing an intermittent "sharp" 4/10 pain below her right breast. She began taking increasing doses of Dilaudid as she felt symptoms were consistent with the beginnings of a sickle crisis. Over the next 24 hrs, pain became constant, 9-10/10, and described as "pressure- as if someone is sitting on my chest." Pain does not radiate, exacerbated with movement and deep inspirations, and little relief with po Dilaudid. Feels worse than usual sickle cell crisis.

 

palpitations, SOB when lying flat, leg swelling, wheezing, any coughing with sputum production (and if so what was the amount, color, odor, and consistency) hemoptysis, abdominal pain, hematemesis, reflux, diarrhea, nausea, vomiting.

Excellent. Pt is quite dyspneic. Cannot walk more than 15 feet before become SOB, which is new for her. No PND, orthopnea, coughing, sputum production, hemoptysis or wheezing. Denies palpitations. No abdominal pain, hematemsis, reflux, N/V/D.

 

Is the patient pregnant as far as she knows? Last normal menstrual cycle?

LMP 10 days ago. Not pregnant as far as she knows.

 

family hx, social hx

FHx: SCD

SHx: Single. In monogamous relationship with boyfriend. No hx STDs. Attends college part-time and works part-time. Social EtOH with a couple of beers per week. No smoking or IVDU.

 

With the sickle disease and OCP I'd run a D-dimer and consider CT scan PE protocol. Don't know enough about history yet but that would be bumped to the top of my differential list.

PE is a good thing to think about in her. What other things are on the differential?

 

Any other questions do we want to ask her before proceeding to physical exam?

[MikeyBoy]

Nice case... Immediately springing to mind...

 

DDX-

 

-Acute chest syndrome: Does she have a pneumonia or infection that is placing her under strain? Recent sicknesses/contacts, UTIs, etc. Does she have her vaccines up-todate if she's asplenic? (H.flu, S.Pneumo, N.Meningitis). Past exacerbation severity?

- PE/Pulm Infarct: Smoke, recent travel, surgeries? Since she's on OCP, chest CT w/contrast may be in her future.

-Pneumo: How's she look- trachea midline? Lung's diminished?

-Anxiety: Stress in her life? Past use/abuse of benzos?

- HyperThyroid- No sweating, abnormal weight loss, tachycardia, palpitations in the past?

 

 

Has she been compliant with her hydroxyurea? (I've seen patients not use it because they view it as a "cancer drug", and that they believe we are experimenting on them) :(

[deborah212]

Very, very good differential. Some others may add one or two more, but excellent.

 

Does she have a pneumonia or infection that is placing her under strain? Recent sicknesses/contacts, UTIs, etc. Does she have her vaccines up-todate if she's asplenic? (H.flu, S.Pneumo, N.Meningitis). Past exacerbation severity?

Asplenic (autosplenectomy). UTD on vaccinations. Denies sick contacts. Sickle cell relatively well controlled with hydroxyurea. +compliance. Last admission for sickle crisis approximately 9 months ago, treated with IVF and IV narcotics.

 

Smoke, recent travel, surgeries? Anxiety: Stress in her life? Past use/abuse of benzos? No sweating, abnormal weight loss, tachycardia, palpitations in the past?

No to all of the above.

 

Physical Exam:

T 98.8 P 88 RR 20 BP 108/60 O2 Sat 99% on 4L

Gen- Appears sick, visibly uncomfortable. Able to speak in full sentences.

HEENT- PERRL. EOMI. Mucus membranes dry. OP without erythema or exudate. No LAD.

Neck- Trachea midline. Neck veins flat.

CV- S1 + S2 RRR no r/m/g. Right chest wall under right breast tender to palpation.

Pulm- Rhonchorous at right base. Otherwise clear.

Abd- +BS Soft/NT

Ext- Left calf tenderness to palpation. No edema. No cords palpated.

Neuro- CNII-XII grossly intact. 5/5 strength against resistance of upper and lower extremities symmetrically.

Skin- No rash.

 

What labs do you want? What do you want to order?

[rev ronin]

D-dimer to rule out PE, ECG to rule out cardiac involvement, CXR for multiple reasons including to r/o pneumonia

[kargiver]

To play devil's advocate: Why the dimer? She has pleuritic chest pain, a low O2 sat, a tender calf, history of sickle cell... do you really think the dimer will be negative? Also, with rhonchi in the right lower base there is likely inflammation and or pneumonia so again, do you really think a dimer will help you here?

 

By Wells Criteria she has at least a 1/6 chance of having a PE... given her presentation, do you think you can get away without spinning her chest? If not, why?

 

Just curious...

 

G

[rev ronin]

PE would indeed be my leading hypothesis at this point, and you're spot on about Wells--I should have skipped the order and jumped to the more expensive tests like CT angiography, given her probability. Thanks for the correction.

 

Was just reading up on SCD, actually. Haven't covered it extensively yet.

[kargiver]

Before jumping to the CTA I would probably do the CXR first. There are many things that can present like this... least expensive testing first.

 

But then again, how do you get around that calf tenderness? Or maybe you don't...

 

Other students?

 

Great case Deborah212 :)

 

G

[EMEDPA]

By Wells Criteria she has at least a 1/6 chance of having a PE... given her presentation, do you think you can get away without spinning her chest? G

 

agree...and by perc you gotta scan her....I like perc better...the whole "is any other dx more likely" is too subjective. I like the hard/fast criteria in perc.

 

PERC Rule 98% sensitive to r/o low risk PE

Age < 50 years

Pulse < 100 bpm

SaO2 > 94%

No unilateral leg swelling

No hemoptysis

No recent trauma or surgery

No prior PE or DVT

No hormone use

[chiaroscuro27]

D-Dimer wouldn't be too beneficial here. Compression ultrasonography would help in determining DVT, spiral CT for PE. Also, I'd like to get an EKG if no one else has mentioned it to check for ischemia.

[Guest guthriesm]

Wouldn't you have to do the D-dimer to be sure insurance will pay for the CT? Plus, while the Xray might help, PEs don't typically show on Xray which could mean an extra charge/test you can skip. I would want the d-dimer first followed by a CT of the chest. History of leg pain- Doppler the leg(s).

[rev ronin]

The CXR is indicated for a bunch of different conditions in the differential, and is itself a pretty cheap test. I don't see any upside to skipping it due to cost. I was originally thinking D-dimer under the "cheap tests first" principle, but as was pointed out to me above, it's almost certainly going to be positive, for one reason or another.

[ajnelson]

Wouldn't you have to do the D-dimer to be sure insurance will pay for the CT? Plus, while the Xray might help, PEs don't typically show on Xray which could mean an extra charge/test you can skip. I would want the d-dimer first followed by a CT of the chest. History of leg pain- Doppler the leg(s).

 

There are multiple d-dimer tests, some more sensitive than others. In my facilities, it can be a lengthy test, taking approximately 45 minutes to an hour. Also, remember any type of inflammation or infection, clot (including DVT) can elevate a d-dimer. If you have a strong suspicion for PE, you should go right for the CT, you want to treat the possible PE as soon as possible. In my practice, I use a d-dimer to disprove a PE in a patient with low probability of PE. In the ED, there is usually no need to order one test in order for another test to be covered. The CXR should be done prior to chest CT, as it is fast, quick, relatively cheap and will let you know pretty quickly if there is another process that needs to be treated instead of waiting 45 minutes for a chest CT (pneumothorax, effusion, pneumonia, etc).

[Guest guthriesm]

Thanks rev ronin and ajnelson- guess I'm spoiled- d-dimers only took about 15 where I worked. Good points about the CXR too.

[deborah212]

The d-dimer has been vetoed. Imaging was pursued in the order kargiver and ajnelson described: stat CXR then CT PE protocol. Her diagnosis may or may not be what you thinking.

 

I will give you those results once you tell what labs should be sent on our young lady who may/may not have a sickle crisis in addition to whatever else is driving her hypoxia...

 

Also, I'd like to get an EKG if no one else has mentioned it to check for ischemia.

Good thinking. NSR at 94. Nl Axis. Nl Segments. No ST changes. Normal ekg.

[chiaroscuro27]

Labs:

 

CBC so we can take a look at hemoglobin and hematocrit, and certainly an ABG.

[Guest guthriesm]

Need a UA and CMP (checking UN, BUN, CO2, K and LFTs specifically)