MOC May 2014: Weekend with Chest Pain

Visit #1: The Saga Begins

You are working on Saturday evening at 7 pm - a time when the word "echo" is interpreted literally by those who perform cardiac stress testing.  

History:

Your patient is 53 year old male nonsmoker who presents with a chief complaint of “it hurts to breath." He describes his pain as sharp and substernal. He says it increases with exertion but is quick to point out that he thinks that is because exertion makes him take deeper breaths. The pain has been present for several days and came on gradually. He says “If I hold really still I have no pain.” 

You assess his cardiac risk: He is sedentary and mildly obese.  He has no known history of diabetes, HTN, or lipid disorder.  His Family History is negative for cardiac disease or PE. 

  

You assess his risk for PE: He denies any recent travel or immobilization.  He also denies leg pain or swelling. He has no personal history of clot.  By Well's criteria he is low risk.  You cannot perform the PERC rule because he is older than 50 years of age. (Shucks) 

He denies fever or chills but has a bit of a dry cough. 

Review of Systems is otherwise negative. 

Vital Signs: 

Temp 99.0, Pulse 92, O2 sat 94% on RA, BP 190/87, RR 18

Physical exam:

General: Speaking in complete sentences, No distress. 

Lungs: normal breath sounds.

CV: Heart sounds normal

Abd: Non-tender, normal bowel sounds, no pulsatile mass.

Extremities: no tenderness, edema or erythema

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What is your Differential Diagnosis (you do this every day...sometimes all day)?

• PE
• Atypical angina
• Chest wall pain
• Pneumonia
• Pleurisy
• Anything else???

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Cognitive Pause:  You have a patient with risk of age, male, maybe untreated hypertension with chest pain which he clearly describes as pleuritic. He attributes pain to deep breaths. He seems to be a good historian, intelligent with no signs of anxiety.

So you order some tests: 

  

EKG: normal sinus rhythm and no acute t wave findings to suggest ischemia. 

Labs:

WBC                               normal

Hgb                                 normal

Trop (istat)                     negative

D-dimer                          0.9

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You can't really ignore that d-dimer... so you get a CT Pulmonary Angiogram...

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Interpretation: Two subsegmental Pulmonary Emboli in the distal pulmonary arterial vasculature. 

Disposition: 

You admit your patient to the Hospitalist service.  He is heparinized and started on warfarin. He is ultimately discharged 3 days later. BP to be further evaluated in follow up. No repeat EKG or trop.

As for you, you finish your shift feeling great - you diagnosed a PE - you may have SAVED A LIFE! Mission accomplished. Almost a decade of med school and residency has been put to good use. You rub your tired eyes and drive off into the sunset (in your Lamborghini Aventador, getting 18 mpg on the highway).

 

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Visit #2: the Plot Thickens

You are working ANOTHER WEEKEND!!! It's been 4 days since your patient's discharge, again Saturday evening.

History:

Your patient returns to the Emergency Department. His chief complaint this time: “I am having more blood clots." He reports that the pain never subsided even transiently with anticoagulation. Being an analytical type guy who has been on the internet, he is concerned that his legs were never looked at with ultrasound. The pain is still intermittent and related to deep breaths and exertion. No new symptoms.

Vitals Signs and Physical exam:

Temp 98.0, Pulse 98, O2 sat 96% RA, BP 154/85

Heart, lung and leg exam still normal.

- - - - -

So you order some tests: 

EKG: Slight decrease in amplitude of R waves in V4-6, no Q waves.

Cognitive Pause: Patient concerned about continuing clots, unlikely to be passing more, but clot burden in legs unknown. Adequately anticoagulated. Clinically does not meet criteria for suspicion of further clots or need for IVC filter.  His pain does not strongly suggest cardiac origin but does have subtle EKG changes. Repeat CT pulmonary angio not indicated. Again, combined study of coronary arteries and central pulmonary circulation unavailable. Venous Doppler noninvasive, maybe reassuring. Patient sent for Doppler.

Labs:

Troponin sent...

Radiology is very prompt and lab not so much. 

The patient returns with his negative Doppler result. 

Then Trop results at 2.34

(Trop can be up with PE but clinically he has no vital sign changes suggesting large PE.)

Disposition:

Patient is admitted again, this time to Cardiology. Echo showed left wall motion abnormality and coronary angiogram later showed significant LAD lesion which was successfully stented. EF reduced but clinically no CHF.


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Oh. Woah.

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Brief Discussion:

1) How did the timing and availability of testing affect this patient’s workup?

2) A small number of us many years ago learned to calculate the Aa gradient as our best “educated guess” of whether a pt had a PE. Technology progressed by leaps and bounds since then, but has it progressed to the point that it can reveal clinically insignificant pulmonary emboli which divert attention from other causes?

3) Should “missed diagnosis” be added to the downside of super sensitive PE imaging?

We will be discussing a great article about the Sensitivity of PE testing in the upcoming Journal Club. Stay Tuned!