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C12) Chest pain, dyspnea, and palpitations in a patient with anxiety
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with an incidental finding.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating patients with an incidental finding.
History
A 23-year old male with a history of anxiety presents with chest pain, palpitations, and shortness of breath. He endorses drinking up to four cups of coffee a day. He endorses several similar episodes over the past few months. He feels his symptoms significantly improved since the onset 30 minutes ago.
Physical Exam
BP: 128/81, HR 77, RR 16, Temp 37.0, O2 saturation 99%. Pulmonary: Lungs clear to auscultation bilaterally. Cardiovascular: Regular rate and normal rhythm, normal S1/S2. Extremities: soft and non-tender to palpation. Hoffman sign negative.
Labs
D-Dimer: 0.01 (nl: <0.50)
Provisional Diagnosis
Select the Dx you believe is most appropriate
The patient is likely having a panic attack considering the unremarkable physical exam and previous episodes. Pulmonary embolism is less likely considering the low D-dimer and normal vital signs.
Well done. You were correct
Potential Acuity
What is your assessment of the likely acuity for this patient?
Well done. You were correct
The patient is likely having a panic attack. However, other etiologies should be ruled out.
First Imaging Study
What is the first imaging study you will order?
A chest X-ray is a good initial test in a patient with dyspnea and chest pain.
Well done. You were correct
Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
Chest X-ray
What best describes the findings on the Chest X-ray?
There is a well-circumscribed incidental mass in the upper, posterior mediastinum.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
A chest CT can be ordered to further evaluate this mass.
Well done. You were correct
Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
Chest CT
What best describes the findings on the Chest CT?
There is a heterogeneous enhancing mass with enhancing components in the left paraspinal gutter that appears to emanate from the T3-4 intervertebral foramen.
Third Imaging Study
What is the next imaging study you will order?
The CT scan strongly suggests the diagnosis. An MRI can be performed in uncertain cases or to evaluate for invasion into the spinal canal if neurologic symptoms exist.
What is your Diagnosis now that you have seen the imaging results?
This mass lesion in the paraspinal gutter is most likely a schwannoma arising from a nerve sheath likely arising from a spinal nerve.
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
The patient should be referred to the appropriate specialist for further management.
Assessment and Plan
Please provide your assessment and plan for this patient
This is a 23-year-old male presenting with an anxiety attack. He was incidentally found to have a posterior mediastinal tumor, most likely representing a schwannoma. Thoracic surgery will be consulted for further evaluation and management. He should follow up with his PCP for anxiety management
Lessons Learned: A posterior mediastinal mass is likely to be a neurogenic tumor. Schwannoma imaging features include a well-circumscribed, heterogeneously enhancing mass.
Socioeconomic Factors: Patients presenting with acute panic attacks should not undergo imaging or invasive procedures if another diagnosis is not highly suspected.
That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.
Contributors:
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator
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