Miss Campbell is a 48-year-old female who has presented to A&E after developing chest pain at home. Work through the case to reach a diagnosis and form a management plan.


History

Presenting complaint

“I’m really scared doctor, I’ve had chest pain for the last 2 hours and I’m feeling out of breath!”

Chest pain:

  • Have you experienced chest pain in the past? Was it like this?
  • Use SOCRATES to gain details of the chest pain
  • Site – Where is the chest pain?
  • Onset
    • Did it come on suddenly or gradually?
    • What were you doing at the time of onset?
  • Character
    • What kind of pain is this? (sharp/aching/crushing)
    • Is it continuous or intermittent?
  • Radiation – Does the pain move anywhere else?
  • Associated symptoms – Are there any other symptoms that seem associated? (e.g. shortness of breath)
  • Timing – When exactly did it start? / How long has it lasted?
  • Exacerbating/relieving factors – Does anything make it better or worse?
    • Is it worse on deep inspiration?
    • Is it worse lying down and made better leaning forward?
    • Is it worsened by exertion?
  • Severity – On a scale of 1-10 how bad is the pain? Has it gotten better or worse?

 

Shortness of breath:

  • When did the shortness of breath start? Did it coincide with the chest pain?
  • Are you short of breath at rest or only during exertion?
  • Have you ever experienced shortness of breath in the past?
  • Have you had a cough or fevers in the last few weeks?
  • Is the chest pain associated with breathing in?
  • Have you noticed any wheezing?
  • Any contact with others who are unwell recently?
  • Any recent long haul travel, surgery or prolonged periods of immobility?

 

Patient’s response

“I’ve never had any chest pain like this in the past doctor, nothing like this at all! It’s on the left side of my chest and it’s really really sharp. It came on suddenly whilst I was on the toilet and it has remained pretty severe since, I’d say about 7/10. It doesn’t move anywhere else but it’s definitely made worse when I take a deep breath, it’s probably 9/10 when I do that. Since the pain started I’ve also been feeling short of breath, I’m not sure it came on at exactly the same time, but it was pretty close.  Lying down, leaning forward and exertion don’t seem to make much of a difference to the pain, but I do get more short of breath when I exert myself.”

“I feel a little short of breath when I’m at rest like this, but it gets a lot worse when I’m walking. I’m normally pretty fit, I manage to get to the shop and back, which is up a hill, without stopping or feeling short of breath. I haven’t had any illnesses in the last few weeks as far as I know and I don’t think I’ve been in contact with anyone else who is unwell. I haven’t noticed any wheezing but I did have some surgery about 3 weeks ago, a laparoscopic hysterectomy for all the fibroids that were causing me trouble. I haven’t been on any holidays in years, I wish I had!”

Past medical history:

  • Cardiac conditions
  • Respiratory conditions
  • Thromboembolic disorders
  • Other medical problems
  • Allergies

 

Drug history:

  • Regular medication
  • Antiplatelets or anticoagulants
  • Contraceptive pill or hormonal replacement therapy
  • Inhalers
  • Over the counter drugs
  • Recreational drugs

 

Social history:

  • Living situation
  • Smoking status
  • Pets
  • Hobbies

 

Travel history:

  • Recent travel? – particularly any areas of high TB prevalence

 

Systemic enquiry:

  • Any other symptoms in other body systems? – weight loss etc

 

Patient’s response

“I have some arthritis in one of my knees, but it doesn’t cause me too much trouble, then I’ve got the fibroids, but I guess they’re gone now. Other than that, I’m pretty well, I don’t even have any allergies!”

“I take some paracetamol and ibuprofen for my knee when it’s bad. No contraceptive pill for me, I’m well past that stage and thankfully haven’t needed any hormonal replacement therapy either.”

“I live with my husband in a flat and neither of us smokes. We used to have a dog but she died last year. My only hobby is selling handmade terrariums on Etsy, does that count?”

“I haven’t travelled anywhere in years and I’ve not got any other symptoms that I’m aware of.”


Examination

As structured ABCDE approach would be the most appropriate way to carry out the initial assessment to ensure the patient is stable.

Airway

  • The patient is able to speak to you in full sentences, therefore her airway is patent.

 

Breathing

  • O2 saturation on air – 89%
  • Respiratory rate – 22
  • Auscultate the lungs to assess air entrya pleural rub is heard over the right lower lobe

 

Intervention

  • Give high flow oxygen via a nonrebreather mask – the patient is hypoxic (aim sats >94%)

 

 

Circulation

  • BP – 130/82
  • Pulse – 132 – regular
  • CRT –  < 2 seconds
  • ECG – shows sinus tachycardia

 

Intervention

  • Gain IV access

 

  • Perform ABG:
    • pH- 7.36
    • PaO2 = 8.00kPa (↓)
    • PaCO2 = 5.5 kPa
    • Bicarbonate – 23

 

 

 

Disability

  • GCS – 15
  • Pupils are equal and reactive to light
  • Normal power in all four limbs

 

Exposure

  • No evidence of external bleeding
  • No rashes
  • Healing port-site wounds from laparoscopic hysterectomy noted (they appear healthy)
  • Calves are soft and non-tender

 

Review the patient’s response to your interventions

  • After you placed the patient on 15L of high flow oxygen, O2 saturations have increased to 94% and her respiratory rate has decreased to 19.

Differential diagnosis

  • Pulmonary embolism
  • Pneumothorax
  • Acute coronary syndrome
  • Pneumonia
  • Aortic dissection

Investigations

Repeat baseline observations:

  • Heart rate
  • Respiratory rate
  • Oxygen saturation
  • BP
  • Temperature

.

ECG – looking for ischaemic changes (?ACS)

.

Bloods:

  • FBC
  • Clotting (hypercoagulability)
  • U&Es
  • LFTs
  • D-dimer (PE/DVT) – useful to rule out thromboembolic disease
  • Troponin (MI)

.

Chest X-ray – ?pneumothorax / ?consolidation

CT Pulmonary Angiogram (CTPA) – the gold standard for diagnosis of PE

Doppler of calves – if deep vein thrombosis is suspected clinically

Baseline observations:

  • Heart rate – 122 BPM
  • Respiratory rate – 20
  • Oxygen saturations – 91%
  • Blood pressure – 128/72
  • Temperature – 36.5

 

ECG – sinus tachycardia

 

FBCunremarkable

Clottingnormal

U&Enormal

LFTnormal

D-dimerraised

Troponinnegative

 

Dopplernegative

 

CTPA – pulmonary embolus visualised in the left pulmonary artery


Diagnosis

Pulmonary embolism 

Pulmonary embolism (PE) involves a blockage of the pulmonary arterial tree by a substance that has travelled from elsewhere in the body through the bloodstream (embolism). Usually, this is due to embolism of a thrombus (blood clot) from the deep veins in the legs, a process termed venous thromboembolism. A small proportion is due to the embolisation of air, fat, talc in drugs of intravenous drug abusers or amniotic fluid.
Symptoms of pulmonary embolism include difficulty breathing and chest pain (often worsened by inspiration). Clinical signs include low blood oxygen saturation, cyanosis, tachypnoea and tachycardia. Severe cases of PE can lead to collapse due to haemodynamic compromise, which can in some cases lead to sudden death¹.

Risk factors

The Wells’ score takes various risk factors into account to predict the likelihood of PE ²

Wells score

  • Clinically suspected DVT – 3 points
  • Alternative diagnosis less likely than PE – 3 points
  • Tachycardia1.5 points
  • Immobilisation/surgery in the previous 4 weeks1.5 points
  • History of DVT or PE – 1.5 points
  • Haemoptysis – 1 point
  • Malignancy (treatment in previous 6 months or palliative stage) – 1 point

 

Miss Campbell’s Well’s score = 6

 

Interpretation of score

  • >4 = PE likely
  • ≤4 = PE unlikely
 

Management 2

Pharmacological treatment

Pharmacological treatment options for confirmed pulmonary embolism (PE) include:

  • Low molecular weight heparin (LMWH)
  • Fondaparinux
  • Unfractionated heparin
  • Oral anticoagulant treatment (warfarin, apixaban, or rivaroxaban)
  • LMWH followed by an oral anticoagulant (dabigatran or edoxaban)

 

Ensure adequate monitoring of anticoagulant treatment (warfarin, apixaban, dabigatran, edoxaban, or rivaroxaban).

.

Duration of treatment

  • Provoked pulmonary embolism (as in this scenario) – offer a Vitamin K antagonist (VKA) to patients with confirmed PE within 24 hours of diagnosis and continue for 3 months. At 3 months, assess the risks and benefits of continuing VKA treatment.
  • Unprovoked pulmonary embolism – offer a VKA long term to patients, taking into account the patient’s risk of VTE recurrence and whether they are at increased risk of bleeding. Discuss with the patient the benefits and risks of extending their VKA treatment
  • The risk of bleeding should always be balanced with the risk of further VTE ²
.

Special circumstances

  • Pregnant patients should remain on LMWH as warfarin is teratogenic
  • Patients with cancer are usually treated with treatment dose LMWH as INR control is difficult to achieve when patients are undergoing chemotherapy. In addition patients with cancer are often at higher risk of bleeding on anticoagulation.

 

Patient education

Ensure Miss Campbell is provided with:

  • Verbal and written information on PE
  • An anticoagulant information booklet
  • An anticoagulant alert card (which they should be advised to carry at all times)

 

  • Verbal and written information on oral anticoagulation treatment, including:
    • How to use them and the duration of treatment.
    • Possible adverse effects and what to do if these occur.
    • The effects of other medications, foods, and alcohol on oral anticoagulation treatment.
    • Monitoring their anticoagulant treatment.
    • How anticoagulants may affect their dental treatment.
    • How anticoagulants may affect activities, such as sports and travel.
    • When and how to seek medical help.

 

Further investigations

You should also be aware that if a patient has an unprovoked PE they will require further investigations:
  • Underlying cancer should be ruled out – CXR / Blood testing / Urinalysis / CT scan
  • Antiphospholipid syndrome testing
  • Hereditary thrombophilia testing (if the patient has first degree relative with DVT / PE)

References

1.  Goldhaber SZ (2005). “Pulmonary thromboembolism”. In Kasper DL, Braunwald E, Fauci AS, et al.Harrison’s Principles of Internal Medicine (16th ed.). New York, NY: McGraw-Hill. pp. 1561–65. ISBN 0-071-39140-1.

2. NICE Guideline. Venous thromboembolic diseases: diagnosis, management and thrombophilia testing. [LINK]

 

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