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Marisa Glashow, MS IV

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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  1. Case Presentation Marisa Glashow, MS IV

  2. 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

  3. 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

  4. Allergies • NKDA • Medications • Lovaza • OCP • PMHx • Ovarian Cysts, Hypercholesterolemia • PSHx • Tonsillectomy • Social Hx • + Tobacco 1 ppd x 4 years

  5. Vital Signs • Temp 97.7 F • HR 111 • RR 22 • BP 130/66 • Sp02 99%, room air

  6. 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

  7. 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

  8. 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

  9. Differential Diagnosis • Pericarditis • Pneumothorax • PE • Gastritis • Costochondritis • Musculoskeletal • Pneumonia • Cholecystisitis • Splenic Rupture

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. CXR vs. Ultrasound

  16. CXR vs. Ultrasound

  17. 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

  18. 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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