Chest Pain Practice Scenario

History of Presenting Complaint

• Site – left sided
• Onset – started the previous day, patient can’t remember if this is sudden or gradual.
• Character – sharp
• Radiation – along the left side of the chest
• Associated symptoms –cough
  • Further details should only be provided if the candidate enquires further. The cough started at around the same time as the chest pain. Initially was non-productive, but today has noticed some blood.
• Timing – present since the previous day
• Exacerbating/ Relieving factors – worse on inspiration, nothing has made the pain better
• Severity – 7/10

ICE

• Ideas – doesn’t know what’s going on, but coughing up blood isn’t a good sign?
• Concerns – since coughing up blood is concerned this could be something serious and life-threatening.
• Expectations – nothing specific. Candidate should notice the anxiety and address this.

Systems review

• Red flags: no fever, no weight loss, no night sweats
• Cardiovascular: no palpitations, no syncope, right leg is swollen and red
• Respiratory: some shortness of breath which has been progressing since arriving at A&E

Past Medical History

• Coeliac disease

Medications

• Combined oral contraceptive pill. Started 15 years ago.

Allergies

• None

Family History

• Grandmother had a stroke at the age of 67

Social History

• Works as a primary school teacher
• Came back by plane from a holiday in Australia last week
• Smokes 5 cigarettes a day for the last 10 years

• Basic observations: temperature 36.5, heart rate 57, oxygen saturations 92%, blood pressure 130/87, respiratory rate 28
• General exam
  • Inspection – comfortable at rest
  • Hands – normal CRT, no clubbing, no CO₂ retention flap
  • Face – no conjunctival pallor, no cyanosis
  • Normal JVP
  • Right leg is red and more swollen than the left.
• Examination of the chest
  • Inspection – no scars
  • Chest expansion equal
  • Trachea central
  • Normal percussion
• Normal breath sounds
• No evidence of added sounds such as wheeze or crackles

What are your key differential diagnoses?

• Pulmonary embolism: The patient is describing a typical history of chest pain of a pleuritic nature, haemoptysis and shortness of breath. A history of COCP use and long-haul air travel combined with a swollen leg should raise suspicion of a DVT precipitant to the episode (1,2).
• Pneumonia: could be an atypical history of pneumonia, however in the absence of fever or a cough productive of sputum this is less likely than a pulmonary embolism (3).
• Musculoskeletal chest pain: should only be considered when other causes have been ruled out.

Please interpret the following ABG.

This ABG shows type 1 respiratory failure (hypoxia and normocapnia) in addition to respiratory alkalosis. This is in keeping with a pulmonary embolism causing hypoxia and hyperventilation (4).

Please calculate this patient’s Wells score?

• Full Wells score can be found in NICE thromboembolic guidelines (5,6)
• Wells score = 7 (DVT signs and symptoms + Alternative diagnosis less likely + Haemoptysis).

What would be the initial steps of management based on the Wells score?

• As the patient scores more than 4 points, a CTPA should be ordered and D-dimer should not be used initially (5, 7).
• NICE guidelines recommend first line treatment should be a DOAC (unless contra-indicated) (5).

How long should treatment be continued for?

• If a DVT or PE is provoked (e.g. following a period of immobilisation after surgery which has since resolved) then treatment should be continued for 3 months. NICE guidelines suggest treatment should continue for longer if the PE is unprovoked (5).

What are the classical ECG findings associated with a pulmonary embolism?

• S1Q3T3 – this refers to the presence of S waves in ECG lead 1, combined with lead 3 Q waves and T wave inversion (1,8).