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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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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

  • SOB associated with pain

  • Dry Cough x 1 week


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


  • 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


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


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


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


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


Atypical Pneumonia

  • Most common organism is Mycoplasma pneumoniae

  • Symptoms:

    • Chest Pain Low-Grade Fever

    • Headache Fatigue

    • Sore Throat Myalgias

    • 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




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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