Case Presentation Marisa Glashow, MS IV

HPI 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 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 Calf Pain Nausea/Vomiting

Ovarian Cysts, Hypercholesterolemia PSHx Tonsillectomy Social Hx Allergies NKDA Medications Lovaza OCP PMHx Ovarian Cysts, Hypercholesterolemia PSHx Tonsillectomy Social Hx + Tobacco 1 ppd x 4 years Lovaza -lowers high triglycerides -metabolizes into omega 3 fatty acids

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

Physical Exam General Respiratory Cardiac No Acute Distress Rapid, shallow breaths CTA bilaterally No wheezes/rales/rhonchi Cardiac +S1/S2 Regular rate and rhythm No murmurs/rubs/gallops

Physical Exam Abdomen Extremities Back 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

Labs 14.0 Total Bili 0.6 Alk Phos 95 AST 16 ALT 11 BHcG (-) U/A (-) 12.0 222 40.7 142 104 12 88 4.5 27.5 0.9

Differential Diagnosis Pericarditis Pneumothorax PE Gastritis Costochondritis Musculoskeletal Pneumonia Cholecystisitis Splenic Rupture

ED Course EKG & Troponins CT Chest with PE Protocol EKG: Normal Sinus Rhythm Troponin: 0.00 CK: 42 CT Chest with PE Protocol Bibasilar consolidation Discharged with Azithromycin CXR No significant findings Maalox & Zantac No improvement Toradol 30mg IV No improvement D-dimer 0.65

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 -MC organism is Mycoplasma pneumoniae -other common organisms include Chlamydia pneumoniae, Coxiella burnetii, Legionalla, and viruses such as Influenza, Adenovirus, Parainfluenza Virus and RSV -Symptoms: Headache Fatigue Sore Throat Myalgias -Signs: -pulse-temp dissociation: normal pulse w/ high fever -since it’s an interstitial PNA, there are 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 In 2009 the Journal of Emergency Medicine published a study called “Chest Radiograph vs. CT scan in the evaluation for PNA. -

CXR vs. CT False Negative CXR more common: Drawbacks to CT: 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 February 2012 the Emergency Medicine Journal published a study titled “Lung ultrasound is an accurate diagnostic tool for the diagnosis of pneumonia in the emergency department” -u/s was the shortest test, taking less than 5 minutes -in 91% of patients with + u/s findings lung consolidation was diagnostic, and 50% of these patients also had an interstitial pattern surrounding the consolidation

CXR vs. Ultrasound -compared the results from ultrasound readings and CXR to the standard of having a diagnosis of pneumonia at discharge -sensitivity of u/s was 99% while the sensitivity of CXR was 67% -these values indicate that ultrasound has less false negatives, and is therefore is a signficantly more sensitive at picking up patients with PNA, than CXR

CXR vs. Ultrasound -if during the course of treatment the physician decided that CT was clinically necessary, then the U/S and CXR results were compared to the CT scan since this test is considered the gold standard -when compared to a CT scan, ultrasound had a sensitivity of 96% and CXR had a sensitivity of 67% -concluded that the CT scan still remained the gold standard, but this test was expensive, time consuming, and exposed the patient to large amounts of radiation -the next test that should be considered is a chest u/s because it is an appropriate diagnostic tool in pts in ED with suspected PNA and it has less false negatives than CXR

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

Bibliography Agabegi, 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.