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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!”

What further questions might be useful to elicit more details surrounding the presenting complaint?

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 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!”

What other questions might you ask to complete your history taking?

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 sadly. 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

What approach would you apply in the initial assessment of Miss Campbell?

An 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

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

Auscultate the lungs to assess air entrya pleural rub is heard over the right lower lobe

 

Circulation

BP – 130/82

Pulse – 132 – regular

CRT –  < 2 seconds

 

Gain IV access

Perform ABG:

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

 

ECG – shows sinus tachycardia

 

Disability 

GCS – 15

Pupils 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.

 

After you place the patient on 15L of high flow oxygen, O2 saturations increase to 94% and her respiratory rate decreases to 19.

Differential diagnosis

What is your differential diagnosis?

Pulmonary embolism

Pneumothorax

Acute coronary syndrome

Pneumonia

Aortic dissection

Investigations

Which investigations would you like to perform?

Repeat baseline observations:

  • Heart rate
  • Respiratory rate
  • Oxygen saturations
  • BP
  • Temperature

.

ECG – ?ischaemic changes

.

Bloods:

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

.

Chest X-ray – ?pneumothorax / ?consolidation

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

Doppler of calves – if deep vein thrombosis is suspected clinically

Click to see investigation results

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 left pulmonary artery

Diagnosis

What is the 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 saturations, 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

What are the risk factors for this condition?

The Wells’ score takes various risk factors into account to predict the likelihood of PE²

Wells score

Clinically suspected DVT – 3 points

Alternative diagnosis less likely than PE – 3 points

Tachycardia1.5 points

Immobilisation / surgery in 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 score = 6

 

Interpretation of score

>4 = PE likely

≤4 = PE unlikely

 

Management

How would you manage Miss Campbell?
Give low molecular weight heparin (LMWH) before imaging if:
  • Well’s score suggests “Likely PE
.
Once PE has been confirmed with CTPA:
  • Start Vitamin K antagonist (e.g. Warfarin) – aiming for an INR of 2-3
  • Once INR is in the target range discontinue LMWH
.
Duration of treatment:3
  • 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 VTE²
.
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.
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 patient has first degree relative with DVT / PE)

References

Click to show

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. British Thoracic Society guidelines for the management of

suspected acute pulmonary embolism 

3. https://cks.nice.org.uk/pulmonary-embolism#!scenario:1

 

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