Chest Pain

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

  1. Understand your relationship with the consulting diagnostic radiologists in the evaluation of a patient with chest pain.
  2. Learn the DDx considerations in chest pain scenarios.
  3. Understand the spectrum of imaging findings in appropriate modalities for evaluating patients with chest pain.

History

Physical Exam

Labs

Provisional Diagnosis

Select the Dx you believe is most appropriate
Choice A is reasonable due to the elevated BNP though there are no rales and it can be elevated from other causes such as pulmonary diseases or renal failure. In this case, the metabolic profile was normal. Choice B is reasonable due to the elevated troponin and CK-MB levels. These can also be elevated in pts with renal failure and right heart overload.
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 may be experiencing an acute MI or be in heart failure.

First Imaging Study

What is the first imaging study you will order?

A chest radiograph could show emergent causes of shortness of breath such as a tension pneumothorax which would require immediate treatment with a chest tube. Findings of CHF or other pathology may be revealed. A wide mediastinum could indicate aortic dissection.
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.

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 CTA of the chest would show the pulmonary arteries in the arterial phase which would allow evaluation for pulmonary emboli. Aortic dissection would also be evident. A chest CT with contrast would not opacify the pulmonary arteries adequately since it slightly delayed when compared to CT angiography (CTA).
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.

View the full study if you'd like to like a look yourself

What is your Diagnosis now that you have seen the imaging results?

There are pulmonary emboli in both the right and left pulmonary arteries in a saddle configuration. There is bowing of the ventricular septum indicating right heart strain.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Substantial clot burden and evidence of right heart strain.

Assessment and Plan

Please provide your assessment and plan for this patient

Because the systolic BP is > 90 mmHg, this is not classified as a "massive pulmonary embolus." However, it could be considered "submassive" due to the clot burden and there is evidence of right heart strain with bowing of the ventricular septum. Treatment options include anticoagulation and possible referral to interventional radiology for thrombectomy.

CTA Chest review

Lessons Learned: A chest radiograph is an appropriate initial study for a patient with chest pain. It could show an emergent finding such a pneumothorax which may require immediate treatment, or other etiologies such as CHF. The chest radiograph is often "normal" in a patient with PE. If there is high suspicion, a CTA would be appropriate.

Socioeconomic Factors: The more expensive CTA of the chest with its much higher radiation dose may not be needed if the radiograph shows a pneumothorax which may require immediate attention. Findings of CHF could be followed by radiographs. This patient was an elderly gentleman with a sedentary lifestyle and likely developed lower extremity DVT as the source of his emboli. He was successfully treated with anticoagulation and a Social Work referral was made for follow/up home health visits.

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