Triage: R flank rads L chest pain, diff breathing x 1 week. Orthopneic.
History of Present Illness: A man in his late 20’s presents with approximately 1 week of right flank pleuritic pain associated with occasional left substernal chest discomfort. He has some shortness of breath. No fever, cough, or other complaints. No history of same. No leg swelling or other complaints. Vital Signs: Pulse ox 99%, very tachypneic, HR 140’s, BP fine
Vital Signs: T: 37.2 °C, HR: 75, RR: 18, BP: 116/82, SpO2: 96%
Physical Exam:
- LUNGS: Unlabored respirations. No splinting. No rales. No wheezing. Diminished breath sounds on the right
- HEART: Normal rate. Regular. Normal heart sounds.
- ABDOMEN: Soft, non-tender. No guarding. No rebound
- GENITOURINARY: Right CVAT
Initial Diagnostic Testing:
- CBC: normal but CRP 11.2 (ULN 1.2)
- Chem: normal except ALT68
- Trop: normal
- CXR: see below
What does the CXR show and what is the most likely diagnosis?
- A) Infiltrate, pneumonia
- B) Normal, pleurisy
- C) Normal, PE
- D) cephalization, CHF
- E) None of the above
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ANSWER:
- A) Infiltrate, pneumonia
- B) Normal, pleurisy
- C) Normal, PE
- D) cephalization, CHF
- E) None of the above – CORRECT – Xray shows elevated right hemidiaphragm, CTA showed subsegmental PE on the right
1-Minute Consult on this topic: Click HERE and scroll.
CASE CONCLUSION: CTA CHEST IMPRESSION: RIGHT UPPER LOBE AND RIGHT LOWER LOBE SUBSEGMENTAL PULMONARY EMBOLI WITH PROBABLE SMALL RIGHT POSTERIOR BASAL INFARCT AND TRACE PLEURAL EFFUSION. NO RIGHT HEART STRAIN.
CASE LESSONS: Chest X-ray findings in PE in descending order of frequency
- Atelectasis
- Elevated hemidiaphragm
- Infiltrate
- Pleural effusion
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