A 25 year old white female reports to the Emergency Room because of sharp left sided chest pain and shortness of breath of one day duration. The patient was in excellent health until yesterday. She was awakened from her sleep by sharp left sided chest pain. The pain worsened with motion and deep breathing. The pain has been progressively increasing in severity and she now has severe left shoulder pain. She complains of shortness of breath and is very apprehensive about dying. She denies any cough, fever, sputum production or hemoptysis.
She is married and had one normal delivery three years ago. She is currently on birth control pills. She has never been hospitalized except for labor and delivery. Review of systems are negative. She denies any past history of venous problems.
She reveals having a similar transitory minor episode of chest pain approximately one year ago while she was vacationing in Michigan.
She works as a computer programmer. She smokes one pack of cigarettes a day for the past eight years. She considers herself a social drinker.
1She has pleuritic pain. What are the characteristics of pleuritic pain?
2Is her pain due to visceral or parietal pleural inflammation?
3 What is the differential diagnosis of pleuritic pain?
4 List diagnoses that could fit the history of this patient as an etiology for pleuritic pain.
Blood pressure 114/80; pulse 118; temperature 37.0 (oral)
She appears to be in moderate respiratory distress. She is well developed and nourished. Pertinent findings include a respiratory rate of 30 and shallow breathing. There is dullness, decreased chest expansion and decreased breath sounds in the left base. There is egophony in the left base. There were no rales or rubs.
Heart reveals PMI in the 5th intercostal space in MCL. The pulmonic component of the second sound is accentuated.
Abdomen, pelvic and rectal exams are normal.
The extremities reveal no evidence of edema, cyanosis or clubbing.
Patient has negative Homan's Sign.
Joint exam revealed shoulder movements complete in range. No warmth or tenderness noted. The rest of the patient's joints are normal.
5 Which of the diagnoses is supported by the physical exam.
6 What type of process is going on in the chest by evidence of exam.
7 What is Homan's Sign?
The Emergency Room physician orders the following tests:
CBC: Hgb 15.0; Hct 43; WBC 11,500; 83 polys, 1 band and 14 lymphs
Arterial blood gases: FI02 .21; pH 7.39; PCO2 30; HCO2 20; PO2 80 and SO2 95%
EKG reveals sinus tachycardia and non-specific S-T-T wave changes axis + 80.
CXR reveals a small pleural effusion in the left base. The left diaphragm is elevated.
Shoulder x-ray is normal.
Decubitus reveals a small amount of fluid in the left pleural space.
8 Does the CBC support your diagnosis?
9 Interpret the blood gases.
10 Calculate the A-a gradient.
11 Interpret the CXR.
12 Does the EKG findings support your diagnosis?
13 What is your explanation for her shoulder pain?
14 What is your working diagnosis now, after the screening lab tests?
15 What additional studies would you like to do?
Lung scan revealed a defect corresponding to the area of pleural effusion.
Pleural tap revealed yellow fluid; protein 3.5 grams; glucose 64 and pH 7.4.
Doppler exam revealed deep vein thrombosis of the left lung.
16 Are you familiar with the way lung scans are reported from a diagnostic consideration of pulmonary embolism?
17 What are the characteristics of pleural effusion of a patient with pulmonary embolism?
18 Why did she develop deep vein thrombosis? Does she have a predisposing factor?
19 Are you surprised by the lack of physical findings for thrombophlebitis in this patient?
20 How often do we have physical findings of thrombophlebitis in patients with proven deep vein thrombosis?
21 Why did she develop deep vein thrombosis? Does she have a predisposing factor?
22 When do you consider pulmonary angiogram in the work-up of a patient suspected to have PE?
The Patient was admitted to the hospital. Repeat lung scan revealed multiple defects.
23 How will you treat her?
24 How long do you want to treat her in the hospital?
25 How long do you want to anticoagulate her as an outpatient and why?
26 Could this problem have been prevented?