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Case Presentation. Marisa Glashow, MS IV. HPI. 21 y/o Female with PMHx ovarian cysts and hypercholesterolemia Substernal Chest Pain x 10 days Pain worsened 3 days ago Radiates to left scapula and epigastrum Sharp, 10/10, constant pain Worse with movement, breathing, and laying supine

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Marisa Glashow, MS IV

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Marisa glashow ms iv

Case Presentation

Marisa Glashow, MS IV


Marisa glashow ms iv

HPI

  • 21 y/o Female with PMHx ovarian cysts and hypercholesterolemia

  • Substernal Chest Pain x 10 days

  • Pain worsened 3 days ago

  • Radiates to left scapula and epigastrum

  • Sharp, 10/10, constant pain

  • Worse with movement, breathing, and laying supine

  • SOB associated with pain

  • Dry Cough x 1 week


Marisa glashow ms iv

HPI

  • Two days prior to onset of symptoms patient strained back

  • One week prior to onset of symptoms patient took two 6 hour car rides

  • Intentional 25 lb weight loss over past 18 months

  • Mild reflux

  • LMP 1 week prior to visit

  • Denies:

    • Fever/chills

  • Calf Pain

  • Nausea/Vomiting


Marisa glashow ms iv

  • Allergies

  • NKDA

  • Medications

  • Lovaza

  • OCP

  • PMHx

  • Ovarian Cysts, Hypercholesterolemia

  • PSHx

  • Tonsillectomy

  • Social Hx

  • + Tobacco 1 ppd x 4 years


Vital signs

Vital Signs

  • Temp 97.7 F

  • HR 111

  • RR 22

  • BP 130/66

  • Sp02 99%, room air


Marisa glashow ms iv

Physical Exam

  • General

  • No Acute Distress

  • Respiratory

  • Rapid, shallow breaths

  • CTA bilaterally

  • No wheezes/rales/rhonchi

  • Cardiac

  • +S1/S2

  • Regular rate and rhythm

  • No murmurs/rubs/gallops


Marisa glashow ms iv

Physical Exam

  • Abdomen

  • Soft

  • + Bowel Sounds

  • Nondistended

  • Tender to palpation slightly distal to xiphoid process that extends to right and left anterior axillary lines

  • Negative Murphy’s Sign

  • Extremities

  • No calf tenderness

  • No edema of lower extremities

  • Back

  • Reproducible tenderness over left scapula

  • Limited ROM of left shoulder


Marisa glashow ms iv

Labs

14.0

Total Bili 0.6

Alk Phos 95

AST 16

ALT 11

BHcG (-)

U/A (-)

12.0

222

40.7

142

104

12

88

4.5

27.5

0.9


Marisa glashow ms iv

Differential Diagnosis

  • Pericarditis

  • Pneumothorax

  • PE

  • Gastritis

  • Costochondritis

  • Musculoskeletal

  • Pneumonia

  • Cholecystisitis

  • Splenic Rupture


Ed course

ED Course

  • EKG & Troponins

    • EKG: Normal Sinus Rhythm

    • Troponin: 0.00

    • CK: 42

  • CT Chest with PE Protocol

    • Bibasilar consolidation

    • Discharged with Azithromycin

  • CXR

    • No significant findings

  • Maalox & Zantac

    • No improvement

  • Toradol 30mg IV

    • No improvement

  • D-dimer

    • 0.65


Marisa glashow ms iv

Atypical Pneumonia

  • Most common organism is Mycoplasma pneumoniae

  • Symptoms:

    • Chest PainLow-Grade Fever

    • HeadacheFatigue

    • Sore ThroatMyalgias

    • Dry Cough

  • Signs:

    • Pulse-Temperature Dissociation

    • No Signs of Consolidation

  • Diagnostic Studies:

    • PA & Lateral CXR-diffuse reticulonodular infiltrates with absent or minimal consolidation

  • First-Line Treatment:

    • Macrolides or Doxycycline


Cxr vs ct

CXR vs. CT

  • Retrospective study determining the incidence of PNA diagnosis in the ED using thoracic CT after obtaining a negative or non-diagnostic CXR

  • Analyzed charts of 1057 patients diagnosed with PNA

    • 97 patients had both CXR and CT performed

      • 26 (27%) of patients had negative or non-diagnostic CXR, but CT showed infiltrate or consolidation consistent with PNA

  • CT has a higher sensitivity than CXR for diagnosing PNA

  • Concluded that future studies need to analyze radiographic diagnostic techniques used for PNA


Cxr vs ct1

CXR vs. CT

  • False Negative CXR more common:

    • dehydrated patient

    • immunocompromised patient

    • portable CXR done at bedside

  • Drawbacks to CT:

    • cost

    • limited availability

    • increased radiation exposure

  • Consider CT:

    • empyema or effusion suspected

    • immunocompromised patient

    • underlying malignancy suspected

    • diagnosis is unclear


Cxr vs ultrasound

CXR vs. Ultrasound

  • Determine whether there is a difference in sensitivity, specificity, and likelihood ratios in the diagnosis of PNA with lung ultrasound vs. CXR

  • Subjects were 120 patients admitted to the hospital with community-acquired pneumonia

  • Ultrasound Exam:

    • Performed by one ED physician who was non-blinded to the subject’s clinical condition

    • Longitudinal and oblique views of the inferior and superior portions of the anterior and lateral chest

    • Two mid-posterior views

  • PA & Lateral CXR read by radiologist who was blinded to the subject’s clinical condition


Cxr vs ultrasound1

CXR vs. Ultrasound


Cxr vs ultrasound2

CXR vs. Ultrasound


Things to remember

Things to Remember…

  • Don’t forget to consider atypical pneumonia

  • When ruling out pneumonia, don’t forget that CXR can be falsely negative

    • Dehydrated patients

    • Immunocompromised patients

  • Ultrasound has a higher sensitivity than CXR for diagnosing pneumonia

  • CT continues to be the gold standard for diagnosing pneumonia


Bibliography

Bibliography

Agabegi, Steven. Step-Up to Medicine. 2. Philadelphia: Lippincott Williams & Wilkins, 2008.

Cortellaro, F. "Lung ultrasound is an accurate diagnostic tool of pneumonia in the emergency department." Emergency Medicine Journal. 29. (2012): 19-23.

Goljan, Edward. Rapid Review: Pathology. 3. Philadelphia: Mosby Elsevier, 2010.

Hayden, G. "Chest radiograph vs. computed tomography scan in the evaluation of pneumonia." Journal of Emergency Medicine. 36.3 (2009): 266-270.

Marrie, TJ. "A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin.." JAMA. 283.6 (2000): 749-755.


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