Interesting Case: How much of a work-up would you have done?

[Surgigal]

Just curious as to what other practicing PAs would have ordered/considered for the DDx. Here's the case as it was presented to me:

 

Pt is a 26-yo G0P0 female with PMH asthma (well-controlled with albuterol prn) and hypothalamic amenorrhea for which she started Yasmin 10 days ago, who now presents with chest pain, diaphoresis, and nausea with one episode emesis- 300 ccs food-material. Pt states she was in her usual state of health until experiencing an "asthma flare-up" at swim practice last night, alleviated with albuterol. Pt c/o "funny feeling in my chest, like my lungs are sore" since that time, but no real pain until the chest pain began 30 minutes ago while grocery shopping. Pain is located at the 5th costal interspace, one fingerbreadth left of the sternal border, is squeezing/burning in nature with minimal radiation to the "entire chest", rated 6/10 at rest and 7-8/10 with deep inspiration/walking, and has not tried any alleviating measures.

 

Vitals:

 

HR: 72

RR: 18

PulseOx: 100% on RA

BP: 92/60

BMI: 22.6

[winterallsummer]

What did the imaging show?

[EMEDPA]

new rx ocp's with pleuritic chest pain is PE until proven otherwise. have seen several with large PE's with this same story including several with a hx of asthma.

can't r/o with a d-dimer on this one as she fails perc criteria and therefore not low risk.

for those not aware this is the perc criteria:

http://www.mdcalc.com/perc-rule-for-pulmonary-embolism/

I like this much better than wells criteria because there are no subjective parts like wells. you either get a point or you don't.

[Teasip]

While concurring with EMEDPA about a PE, in a "young" person with a hx. of actual RAD, especially if a borderline/below normal BMI (normal in this situation), you also need to take into consideration a spontaneous ptx with progressive deflation of the involved lung. If this scenario were to be a spontaneous ptx. it may be difficult to see on a plain PA film of the chest due to the cardiac silhouette since it is subjectively localized to the midline of the chest. I had a young, thin male with a hx. of RAD come into the ED early afternoon years ago with SSCP that occurred while sitting at his work desk. CXR showed his left lung being about the size of his fist.

[Timon]

Just spit balling but how were the lung sounds? Could it be possible that due to the swimming the patient could be experiencing an onset of a dry drowning?

[EMEDPA]

lung sounds, unfortunately can be misleading. you can miss pneumothorax, etc in someone with a nl sat and "clear lungs".

[rcdavis]

Question was how much w/u..

Here in my ED she would get CBC, bmp, cxr EKG enzymes, and PERC notwithstanding, DImer. ( understanding I would only believe positive).

 

Family hx re cardiac or rheumatic dz would be nice, as would cardiac risk factors.

 

Agre with Eric: new onset cp with newly started bcp gets my attention, even though not tacky-tachy.

 

Exertional c/p in females does also.

 

Regardless, that's what I would do until further data is known.

 

She would not be discharged without these.

[EMEDPA]

one of my pa partners had a very similar case recently sent in by an md in the community for "severe asthma, please arrange IV steroids and continuous neb tx".

initially txd as asthma without improvement. cta showed huge b/l pe's...

[EMEDPA]

DImer. ( understanding I would only believe positive).

 

.

why do it then? if a + dimer gets a cta and a neg dimer gets disregarded?

one of my partners recently almost sent home a big PE with a neg dimer from our obs unit. already had been there for 24 hrs with the full cardiac workup including treadmill, etc. At sign out the oncoming provider said " so, pulse of 110 at rest for the entire visit? better scan her". he was right. my understanding of the d-dimer is that it's accuracy decreases with time so a 7-10 day old PE may have already peaked the d-dimer and it's now back to nl.

[Teasip]

With a separate ED group I later worked with, patients couldn't be discharged tachycardic w/o a noted source or written documentation addressing same.

[bobbyg]

This is how I evaluate for PE.

PERC neg: no further testing

Low risk wells: d-dimer

Moderate or higher risk Wells:CT chest

 

 

These all have similar negative predictive values when applied to the right population. The subjective portion of wells is just for the patient that the only thing that would make sense is PE so get the scan.

Risk of cancer of a CT chest in a 20's female is 1:300 so I think it is worth thinking about a d-dimer and documenting a rational to testing.

[Guest JMPA]

Just curious as to what other practicing PAs would have ordered/considered for the DDx. Here's the case as it was presented to me:

 

Pt is a 26-yo G0P0 female with PMH asthma (well-controlled with albuterol prn) and hypothalamic amenorrhea for which she started Yasmin 10 days ago, who now presents with chest pain, diaphoresis, and nausea with one episode emesis- 300 ccs food-material. Pt states she was in her usual state of health until experiencing an "asthma flare-up" at swim practice last night, alleviated with albuterol. Pt c/o "funny feeling in my chest, like my lungs are sore" since that time, but no real pain until the chest pain began 30 minutes ago while grocery shopping. Pain is located at the 5th costal interspace, one fingerbreadth left of the sternal border, is squeezing/burning in nature with minimal radiation to the "entire chest", rated 6/10 at rest and 7-8/10 with deep inspiration/walking, and has not tried any alleviating measures.

 

Vitals:

 

HR: 72

RR: 18

PulseOx: 100% on RA

BP: 92/60

BMI: 22.6

 

stat chest cta r/o PE, it will also cover other potential life threatening causes of cp.

[Surgigal]

Thank you to all who responded!

 

We were initially thinking PE, but D-dimer was equivocal (500), and CTA was negative. UTOX negative. My attending suggested a troponin, which ended up elevated at .16 (subsequently bumping to .24, before trending down to .21, then .14). CK-MB was 12.4, and ECG showed borderline t-wave changes in the inferior leads, which persisted on subsequent ECG in the ED. Nitro x 3 alleviated her pain. We got a cards consult, who felt it was an NSTEMI, and admitted to tele. Subsequent echo and cardiac cath were clean.

 

Pt had no personal or family history of heart disease, no HTN, no HLD (total cholesterol 150, HDL 60, triglycerides 106). Pt was a regular runner (10-15 miles/week) and swimmer (2-3 miles/week), and ate a diet relatively low in saturated fat for an American. She was under no particular increased stress, and had no history of anxiety or substance abuse disorder. Pt states she had never smoked, drank 1-2 glasses of wine/month, and denied any ilicit drug use. Pt denied any recent viral illness, and as above, echo and cath didn't indicate any myocarditis or tako-subo's. Or plaque, for that matter.

 

Several things bother me about this case, even though I suppose she technically met the criteria for NSTEMI.

1) we don't have a baseline ECG to which we can compare

2) The bump in troponin/CK-MB were relatively mild, and rather short-lived. Typically they remain elevated for longer than 3-6 hours during MI, and trend much higher.

3) I'm honestly surprised the troponin came back elevated in a young pt with atypical chest pain (pt could localize pain with 1 finger), especially given her lack of risk factors. I'm even more surprised cards cath'd her, especially since her echo was clean. (though I suppose they had to look for SOME reason for her symptoms).

4) There doesn't appear to be a definitive cause for her NSTEMI, if indeed that's what happened.

[EMEDPA]

maybe she just had a viral myocarditis....

[Simplify]

I'm only a student, but I'll bite.

Female, t-wave changes, pain alleviated w/ nitro, slightly elevated troponin and clean cath... maybe prinzmetal angina or some type of coronary vasospasm?

[Teasip]

There is a potential explanation, especially if the discomfort were more commonly noted at rest. Prinzmetal's angina resulting in a non-transmural MI (NSTEMI). It would account for the enzyme bump as well as symptoms, and would also allow for normal angiography while asx. Typically seen in younger individuals versus older folks. Simplify beat me to the punch.

[Simplify]

There is a potential explanation, especially if the discomfort were more commonly noted at rest. Prinzmetal's angina resulting in a non-transmural MI (NSTEMI). It would account for the enzyme bump as well as symptoms, and would also allow for normal angiography while asx. Typically seen in younger individuals versus older folks. Simplify beat me to the punch.

 

Looks like all that tuition might be worth it after all :)

[EMEDPA]

This is how I evaluate for PE.

PERC neg: no further testing

Low risk wells: d-dimer

Moderate or higher risk Wells:CT chest

 

 

These all have similar negative predictive values when applied to the right population. The subjective portion of wells is just for the patient that the only thing that would make sense is PE so get the scan.

.

here is the wells criteria:

http://www.mdcalc.com/wells-criteria-for-pulmonary-embolism-pe/

the reason I don't like wells is #2. if someone thinks in this pt for example that the most likely cause is a chest wall strain from playing volleyball last week because they reproduce pain with palpation once the pt doesn't get the points AND their wells score is zero. perc takes all the guessing out of the equation. everything is a yes/no question.

my method is perc + common sense.

perc neg done unless also has some comorbidity like metastatic ca or bad FH like "my whole family gets dvt's but I have never had one" (which could still be perc neg).

[paraguru]

Thanks for the Calcs EMEDPA. I have to agree that the R/O for PE had to come first. My small rural ER lab doesn't have D-dimers so I would have had to ship her for the CTA.

[mackjacks]

I'd be annoyed about the cath if I were her. Hope she has good insurance.

[rcdavis]

Annoyed by the cath???

Why?

 

Is clear she did not have pe( I am not sure I would have done CTA first, until I knew the enzyme results... Simply due to dye load..) But young women do get atypical chest pain, often cad, or even takotsubo cardiomyopathy, which cath demonstrates...

 

If you think she shoulda been annoyed, what do you think should have been done to her.. And why?

[True Anomaly]

3) I'm honestly surprised the troponin came back elevated in a young pt with atypical chest pain (pt could localize pain with 1 finger), especially given her lack of risk factors. I'm even more surprised cards cath'd her, especially since her echo was clean. (though I suppose they had to look for SOME reason for her symptoms)._

 

Amal Mattu, who is an emergency doc that is considered an expert in emergency cardiology, has recently advocated that, above all, the HPI is the single most important risk factor for coronary disease. Even at that age, chest pressure that's worsened with exertion and relieved with rest, occurring for less than 30 minutes at a time- you better pursue a cardiac etiology, even if its just EKG and enzyme rule-out.

 

If you like playing along at home, check out the EMRAP from June 2012 where he discusses the changing paradigm for women and ACS. Kinda scary stuff

[mackjacks]

Annoyed by the cath???

Why?

 

Is clear she did not have pe( I am not sure I would have done CTA first, until I knew the enzyme results... Simply due to dye load..) But young women do get atypical chest pain, often cad, or even takotsubo cardiomyopathy, which cath demonstrates...

 

If you think she shoulda been annoyed, what do you think should have been done to her.. And why?

I'm imagining myself in her shoes, which is easy to do since we are very similar age and health-wise. If I had slightly elevated troponins that were heading back down, no ST elevation, nitros had relieved the pain, AND knowing I had no risk factors, ate well/exercised, and it was the first time it had happened, I'd deny any further treatment at that time.

 

Wasn't saying her management was wrong (obviously it was the most thorough option to CYA), and if I were the PA and a cardio consult wanted to cath her I wouldn't argue one bit.

[CAdamsPAC]

Amal Mattu, who is an emergency doc that is considered an expert in emergency cardiology, has recently advocated that, above all, the HPI is the single most important risk factor for coronary disease. Even at that age, chest pressure that's worsened with exertion and relieved with rest, occurring for less than 30 minutes at a time- you better pursue a cardiac etiology, even if its just EKG and enzyme rule-out.

 

If you like playing along at home, check out the EMRAP from June 2012 where he discusses the changing paradigm for women and ACS. Kinda scary stuff

 

A very long time ago a PA in the Army told me that if you listen to the patient, they will tell you what's wrong with them...............80% of the dx is in the hx was another of his witisisms.

[CAdamsPAC]

Amal Mattu, who is an emergency doc that is considered an expert in emergency cardiology, has recently advocated that, above all, the HPI is the single most important risk factor for coronary disease. Even at that age, chest pressure that's worsened with exertion and relieved with rest, occurring for less than 30 minutes at a time- you better pursue a cardiac etiology, even if its just EKG and enzyme rule-out.

 

If you like playing along at home, check out the EMRAP from June 2012 where he discusses the changing paradigm for women and ACS. Kinda scary stuff

 

A very long time ago a PA in the Army told me that if you listen to the patient, they will tell you what's wrong with them...............80% of the dx is in the hx was another of his witisisms.