A 34-year-old woman comes to the emergency department with sharp, right-sided chest pain that worsens with inspiration, movement, coughing, and sneezing. She developed dry cough, malaise, fever, and rhinorrhea 3 days ago. The patient has pain when sitting up; she lies on her right side and sits with her torso hunched during the interview. She has a 15-pack-year smoking history and takes an estrogen-progestin oral contraceptive.
Temperature is 37.4 C (99.4 F) , pulse is 78/min, and respirations are 16/min. Pulse oximetry shows oxygen saturation of 97% on room air. BMI is 22 kg/m².
Lung examination reveals a scratching sound in the right base. There is no lower extremity edema.
Chest x-ray and ECG are unremarkable. D-dimer is within normal limits.
Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

Sharp, focal pain that worsens with movement (eg, deep breathing, coughing, sneezing) is consistent with pleurisy (pleuritis), defined as inflammation of the parietal and serous lung pleura. Life-threatening causes of pleurisy include pulmonary embolism, pneumothorax, pneumonia, and myocardial infarction and should be considered before less serious conditions. This patient's young age and normal chest x-ray, ECG, and D-dimer make such conditions less likely. Moreover, pleuritic chest pain 3-4 days after a viral prodrome is consistent with viral pleurisy, one of the more common causes of pleuritis. Others include inflammatory bowel disease, malignancy, chronic kidney disease, and rheumatologic diseases (eg, lupus pleuritis). Etiologies of viral pleurisy include influenza, coxsackieviruses, adenoviruses, and Epstein-Barr virus, which can occur with or without an initial viral prodrome. Treatment is supportive; nonsteroidal anti-inflammatory drugs (NSAIDs) effectively control pain and pleural inflammation. Although indomethacin is the only NSAID studied in humans, others are also presumed to be effective. (Choice A) Azithromycin is used in some cases of bacterial pneumonia, which can occur after an initial viral prodrome. Patients usually worsen with productive cough, fever, and shortness of breath. This patient's normal vital signs and chest x-ray make this less likely. (Choice B) Although a CT chest without contrast can be helpful to further characterize pulmonary nodules, infections, or effusions, it is not necessary for the evaluation of pleurisy in the setting of a normal chest x-ray. (Choice C) A CT pulmonary angiogram can diagnose venous thromboembolism. The patient has a low probability of venous thromboembolism based on Wells criteria (eg, leg swelling, tachycardia, signs or symptoms of deep venous thrombosis, immobilization). This, combined with negative D-dimer testing, significantly reduces the need for further testing. (Choice D) Echocardiogram can evaluate for valvular heart disease, congestive heart failure, or right ventricular failure in acute pulmonary embolism. However, this patient's normal ECG, right-sided chest pain, negative D-dimer, and lack of lower extremity edema make these less likely. Educational objective: Pleurisy is inflammation of the lung pleura, which can cause severe pain with movement (eg, deep breathing, coughing). Viral pleuritis is a common cause and may present with or without an initial viral prodrome. Nonsteroidal anti-inflammatory drugs (eg, indomethacin) effectively treat the pain and pleural inflammation. __________ References: Pleurisy. (http://www.ncbi.nlm.nih.gov/pubmed/17508531)

A 34-Year-Old Woman Comes to the Emergency Department with Sharp