It’s been a busy afternoon. You are working on admissions with one patient chart in each hand and a cappuccino in your third hand. Triage walks back a haggard-appearing twenty-something with chest pain.  “Can’t that go to fast-track?” you suggest hopefully.  No luck.

“This guy was seen yesterday for the same thing,” answers the triage nurse. “You’re up,” he smiles, handing you a third chart. “Think of it as a few more RVUs.” You grunt something unintelligible, smile, and clamp the offered chart between your front teeth (figuratively, of course) like the trained gun-dog that you are.

The story is simple. “My chest is killing me, and that Motrin stuff is not cutting it,” the patient says. “It really hurts to breathe.” He woke the other morning with this upper sternal, pleuritic chest pain. There are no other exacerbating features, no fever or cough. The pain does not sound cardiac in nature. Vitals are normal, including an O2 sat of 98% on RA. The exam is normal, except for poor air movement on both sides due to severe pleuritic chest pain. Although the symptoms are low risk, you order pain meds and a screening evaluation including cardiac enzymes, an EKG and a D-dimer. There are no PE risk factors, and you are considering a chest CT – but you decide to look at yesterday’s chest X-ray first.
Which turns out to be a very productive use of your time. Radiology reading on this film from yesterday is “no acute findings.” But by this time, you are looking for something very specific.


What does the X-ray show? What do you do next? Conclusion on next page



# Pts w/ CPEDL 2011-05-06 14:35
This patient went to the ED initially. If this patient would have waited and went to a clinic for follow-up, as opposed to going to the ED again, would the results have been worse? What are the implications of this example for patients with unresolved chest pain after an initial ED visit?

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