Pleuritic chest pain Flashcards
A 30-year-old woman presents with a three-day history of shortness of breath, cough, pleuritic chest pain and fever. She has had several episodes of haemoptysis, which she describes as blood-stained sputum. She has a background of a **previous deep vein thrombosis **two years ago whilst on the combined oral contraceptive pill. She is a non-smoker.
How would you manage this patient?
ABCDE approach
A
- Ensure airway patency
- Any sign of compromise, call for help early
B
- Monitor SpO2, RR
- Give high flow O2 via NRB
- Look, listen and feel for fatigue, increased work of breathing, consolidation, crepitations, fluid, wheeze
- If concerned, I’d get a mobile CXR
C
- Monitor HR, BP, listen to heart sounds
- 12-lead ECG, then continuous 3-lead ECG
- Establish large bore IV access & take bloods
- Take ABG for quick PaO2 and lactate
- Assess fluid status - JVP, CRT peripherally and centrally, mucosal membranes
- Since 3/7 Hx of fever > likely hypotensive > give IV fluid bolus
- Monitor UO - if drowsy > consider catheter
D
- BM, temperature
- AVPU/GCS to assess for confusion
- Focused neuro exam
- Abdo + limb exam to look for sources of infection, DVT
Her observations are:
SpO2 94% on RA, RR 32, HR 110, BP 90/60, T 38
What investigations would you do?
- The patient is significantly tachypnoeic, tachycardiac and pyrexic. I am concerned that she is septic, therefore I would make sure sepsis 6 is administed. She is clearly working hard to maintain her SpO2 at 94%
Bedside
- Monitor SpO2, give high flow oxygen
- ABG for acid-base status & lactate
- Monitor UO (with a catheter if necessary)
Bloods
- FBC, CRP, U&Es, LFTs, D-dimer (depending on pretest Wells score)
- Blood cultures, sputum MC&S if feasible
- Urine dip for pneumococcal or legionella antigen and urine MC&S
Imaging
- CXR (consolidation, effusion)
- Consider CTPA if PE suspected
As mentioned, I would make sure that sepsis 6 is adminstered, including IV antibiotics and further IV fluids.
Here are the results of some investigations.
Bloods
Hb 130, WBC 16, Neut 13, Plt 500, CRP 75, Urea 17 mmol, D-dimer 1.76 (0.1-0.45)
CXR: Hazy opacification in the LLZ, ECG: sinus tachycardia
The patient appears to have community acquired pneumonia with evidence of pleurisy based on her increased WBC, neutrophilia, raised CRP and her LLZ opacification on CXR.
The D-dimer can be elevated for many reasons, such as CAP, not just PE and DVT. I would go by my investigation findings. PE can certainly happen simultaneously with CAP and she is at increased risk given her previous DVT.
How would you interpret the D-dimer result?
The elevated D-dimer can very well be because of her pneumonia. However, given her previous DVT, being septic, slight thrombophilia and haemoptysis, she is definitely at higher risk of thromboembolism.
I would want to know if she is still on COCP.
I would calculate her PE Well’s score and examine her limbs for DVT. She would be at higher risk, so I would discuss with my registrar to consider CTPA.
What is your differential diagnosis?
- Sepsis 2nd to CAP
- Pulmonary embolism
The patient does not respond to initial treatment, what will you do?
I would inform my registrar and ask for their urgent input, whilst also contacting ITU to ask for their review and input. It may be that the patient would require admission to ITU.
What input would intensive care provide?
- **Higher level of care **- nursing & continuous monitoring
- Arterial line (ABG and lactate monitoring)
- Venous line - intensive fluid replacement
- Vasopressors
- Intubation & ventilation if required
How would you demonstrate to your senior colleagues the severity of this patient’s presentation?
Presentation, observation and investigation
Also calculate CURB-65
Urea > 17 mmol, RR > 30 and sBP < 90 > CURB-65 = 3 - severe risk group
CURB-65 of 3-5 indicates that the pt needs admission and potentially higher level care involvement
What would you say to the patient if they were in front of you now?
Intro
* First ensure privacy, introduce myself and my role
* Ask if she wants a family member
* Ask what has she understoof so far of what had been happening in the hospital and what we are treating her for
Explanation
* In simple language > very bad chest infection, she needs to stay in the hospital and we might even get her under more intensive care
* Explain that treatment with antibiotics and fluid
* If we are still worried about PE, I would explain that given how unwell she is and her previous blood clot in the leg, that I am also concerned that she might have a clot in her lungs. To rule that out, I will send her for a CT scan.
* Explain that she should start to feel better in the coming days.
End
* Ask her to explain it back to me and ask if she had any questions for me.
* Ask her if she’d like me to call anyone.
You now have one minute to handover the patient in this scenario to your registrar/consultant as if you were at the Acute Medical Handover.
S
- 30-yo female admitted with sepsis 2nd to CAP
B
A/w 3/7 Hx of SOB, fever, cough, haemopthysis and pleuritic chest pain. PMHx significant for DVT whilst on COCP, otherwise fit and well.
A She was tachypnoeic (32), tachycardiac, pyrexic. I have administered sepsis 6. She has neutrophilia, CRP of 75, and raised lactate at 2.7. Her CXR showed LLZ consolidation. Her D-dimer was noted to be elevated. She has a CURB-65 score of 3.
R
She needs admission to AMU. I am also concerned about simultaneous PE given her raised D-dimer, intravascular depletion, immobility and previous Hx. She needs an urgent review to decide whether CTPA needed given her elevated D-dimer and previous DVT. I think she will also need early ITU review.
