1. Case Presentation
Marisa Glashow, MS IV

2. 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

3. 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

4. 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

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

6. 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

7. 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

8. 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

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

10. 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

11. 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

12. 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. -

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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):
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 (2009):
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 (2000):