Marisa Glashow, MS IV

•21 y/o Female with PMHx ovarian cysts and hypercholesterolemia

•Substernal Chest Pain x 10 days

•Pain worsened 3 days ago

•Radiates to left scapula and epigastrum

•Sharp, 10/10, constant pain

•Worse with movement, breathing, and laying supine

•SOB associated with pain

•Dry Cough x 1 week

HPI

HPI•Two days prior to onset of symptoms patient strained back

•One week prior to onset of symptoms patient took two 6 hour car rides

•Intentional 25 lb weight loss over past 18 months

•Mild reflux

•LMP 1 week prior to visit

•Denies:

•Fever/chills • Nausea/Vomiting•Calf Pain

Allergies•NKDA

Medications•Lovaza•OCP

PMHx•Ovarian Cysts, Hypercholesterolemia

PSHx•Tonsillectomy

Social Hx•+ Tobacco 1 ppd x 4 years

Vital Signs

• Temp 97.7 F• HR 111• RR 22• BP 130/66• Sp02 99%, room air

Physical ExamGeneral•No Acute Distress

Respiratory•Rapid, shallow breaths•CTA bilaterally•No wheezes/rales/rhonchi

Cardiac•+S1/S2•Regular rate and rhythm•No murmurs/rubs/gallops

Physical ExamAbdomen•Soft•+ Bowel Sounds•Nondistended•Tender to palpation slightly distal to xiphoid process that extends to right and left anterior axillary lines•Negative Murphy’s Sign

Extremities•No calf tenderness•No edema of lower extremities

Back•Reproducible tenderness over left scapula•Limited ROM of left shoulder

Labs14.0

12.0 222

40.7

142

4.5

104

27.5

12

0.9

88

Total Bili 0.6Alk Phos 95AST 16ALT 11

BHcG (-)U/A (-)

Differential Diagnosis

• Pericarditis• Pneumothorax• PE• Gastritis• Costochondritis• Musculoskeletal• Pneumonia• Cholecystisitis• Splenic Rupture

ED Course• EKG & Troponins

• EKG: Normal Sinus Rhythm• Troponin: 0.00• CK: 42

• Maalox & Zantac• No improvement

• Toradol 30mg IV• No improvement

• CXR• No significant findings

• D-dimer• 0.65

• CT Chest with PE Protocol• Bibasilar consolidation• Discharged with Azithromycin

Atypical Pneumonia

• Most common organism is Mycoplasma pneumoniae• Symptoms:

• Chest Pain Low-Grade Fever• Headache Fatigue• Sore Throat Myalgias• Dry Cough

• Signs:• Pulse-Temperature Dissociation• No Signs of Consolidation

• Diagnostic Studies:• PA & Lateral CXR-diffuse reticulonodular infiltrates with absent or

minimal consolidation

• First-Line Treatment:• Macrolides or Doxycycline

CXR vs. CT• Retrospective study determining the incidence of PNA diagnosis

in the ED using thoracic CT after obtaining a negative or non-diagnostic CXR

• Analyzed charts of 1057 patients diagnosed with PNA• 97 patients had both CXR and CT performed

• 26 (27%) of patients had negative or non-diagnostic CXR, but CT showed infiltrate or consolidation consistent with PNA

• CT has a higher sensitivity than CXR for diagnosing PNA

• Concluded that future studies need to analyze radiographic diagnostic techniques used for PNA

CXR vs. CT

• False Negative CXR more common:• dehydrated patient• immunocompromised patient• portable CXR done at bedside

• Drawbacks to CT:• cost• limited availability• increased radiation exposure

• Consider CT:• empyema or effusion suspected• immunocompromised patient• underlying malignancy suspected• diagnosis is unclear

CXR vs. Ultrasound• Determine whether there is a difference in sensitivity, specificity,

and likelihood ratios in the diagnosis of PNA with lung ultrasound vs. CXR

• Subjects were 120 patients admitted to the hospital with community-acquired pneumonia

• Ultrasound Exam:• Performed by one ED physician who was non-blinded to the

subject’s clinical condition• Longitudinal and oblique views of the inferior and superior

portions of the anterior and lateral chest• Two mid-posterior views

• PA & Lateral CXR read by radiologist who was blinded to the subject’s clinical condition

CXR vs. Ultrasound

CXR vs. Ultrasound

Things to Remember…

• Don’t forget to consider atypical pneumonia

• When ruling out pneumonia, don’t forget that CXR can be falsely negative• Dehydrated patients• Immunocompromised patients

• Ultrasound has a higher sensitivity than CXR for diagnosing pneumonia

• CT continues to be the gold standard for diagnosing pneumonia

BibliographyAgabegi, Steven. Step-Up to Medicine. 2. Philadelphia: Lippincott

Williams & Wilkins, 2008.Cortellaro, F. "Lung ultrasound is an accurate diagnostic tool of

pneumonia in the emergency department." Emergency Medicine Journal. 29. (2012): 19-23.

Goljan, Edward. Rapid Review: Pathology. 3. Philadelphia: Mosby Elsevier, 2010.

Hayden, G. "Chest radiograph vs. computed tomography scan in the evaluation of pneumonia." Journal of Emergency Medicine. 36.3 (2009): 266-270.

Marrie, TJ. "A controlled trial of a critical pathway for treatment of community-acquired pneumonia. CAPITAL Study Investigators. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin.." JAMA. 283.6 (2000): 749-755.