Case 9: Positional Pain

Three Cases of Positional Chest Pain

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POSITIONS: These three women who presented with POSITIONAL right flank pain both had the same final diagnosis. What do you think it was?

A woman in her 30’s with a history of asthma and migraines and a recent URI which has resolved presents with right flank pain for 3 days which she thinks is a muscle strain from lifting her three month old. The pain is worse with lying down and increased with respirations. She denies fever, hematuria, dysuria, vomiting and shortness of breath. Her vitals and exam are essentialy normal. UA shows 200 RBC’s. CXR shows a faint right sided infiltrate.

Another woman in her 30’s presents with four days of intermittent right flank pain that is very positional. It is worse when she lies down. It is relieved by standing up. It is also a little bit worse sometimes after meals. It has been intermittent, lasting up to 20 minutes. It also seems like it is difficult for her to take a deep breath. She denies shortness of breath, fever, vomiting and hematuria and dysuria. She was seen at another ER yesterday, had a negative UA and was sent home with a diagnosis of biliary colic. She has polycystic ovarian syndrome and her only medication is the pill. Vitals and exam are normal. UA is negative as is the chest X-ray.
The third woman was referred to the ED by her pain specialist. She had “refractory” right flank and abdominal pain that had not been relieved by a “prophylactic” cholecystectomy and the plan was to do an intercostal rib block Monday in the office. The patient told the EP that the pain after the surgery was different than before. It was in the right flank and worse with inspiration and twisting movement. She had a cough productive of phlemg and blood which she had been told was bronchitis. She also said that her face and arms seemed swollen. Her chest x-ray is shown below

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ANSWER:
Pulmonary Embolism. The CXR shows an elevated hemidiaphragm

Excerpt on PE from “Quick Essentials“

Sources: 20% neck & arms DVT, 20% calf DVT, 60% proximal leg DVT, Other: renal/hemorrhoidal vein
PE Sx: SOB:84, Flank/chest/back pain (pleuritic:74), splint, sweating, syncope:13(#1 miss is syncope)
Large PE: SOB +/- pain > hypoxia, painless syncope, hypotension.
Small PE: Pleuritic pain, (SOB), normal VS and pulse ox, cough:53, hemoptysis:30
PE Signs: RR >16:92, rales:58, P2 > S2:53, ?HR:44, temp:43, murmur, wheeze, rub, JVD, Tender: 13
Well�s Criteria: 3points: suspect DVT,no good alt. dx. 1.5points: HR>100,OR/immob<4wks,h/o PE/DVT. 1point: CA,hemoptysis
Add points: <2: low risk(3.5%). 2-6: medium risk(20%). >6: high risk(67%)
PE EKG: (Transient): tachy:44, Twave?:42, ST?/?:26/16, P pulmonale(lead II):2-31%
Nl: 12, S1Q3T3: 12, fake MI: 10, incomplete RBBB: 10, AVB, L-axis > R-axis
PE CXR: Elevated Hemidiaphragm >Atelectasis > Cardiomegally >Effusion >Infiltrate >
Enlarged pulmonary artery >Oligemia >vascular cutoff (Westermark)
PE Echo: Positive in large PE: dilated RV, intracardiac thrombi, ^right sided pressures
PE Labs: ABG: nl Aa:10; Ddimer:85%, age >60 too many false positives. Trop? if RV dysfunction
Pretest IOS: Presentation: classic, typical, atypical; Altenative Dx?; Major RF present
V/Q: Pros: Pt ? RI or nl CXR(only 10% non-diagnostic (low, indeterminate & intermediate probability))
PIOPED: VQ results and % ? =PE: nl:2; low:16; intermed:41; high:41; r/o PE ? low IOS & low prob. scan
CT Angio: Sensitivity varies by #slice CT: Benefits: unstable pt, COPD/abnl CXR, alt dx, specific, rapid
Multi-detector CT available since 1998