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Marisa Glashow, MS IV

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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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Presentation Transcript
slide1
Case Presentation

Marisa Glashow, MS IV

slide2
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
slide3
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
slide4
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
slide6
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
slide7
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
slide8
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

slide9
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
slide11
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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