A 34-year-old woman comes to the physician with dyspnea and severe chest pain. The pain is localized on the left side and increases with inspiration. She also had 1 episode of hemoptysis. Two days ago, the patient flew back to the United States from a trip to Central Asia. She does not use tobacco, alcohol, or illicit drugs. She is sexually active with 1 partner and uses oral contraceptives. Her father died of a myocardial infarction at age 52. Her temperature is 36.7 C (98 F), blood pressure is 110/66 mm Hg, pulse is 106/min, and respirations are 28/min. Which of the following most likely accounts for this patient's chest pain?

Question

A 34-year-old woman comes to the physician with dyspnea and severe chest pain.  The pain is localized on the left side and increases with inspiration.  She also had 1 episode of hemoptysis.  Two days ago, the patient flew back to the United States from a trip to Central Asia.  She does not use tobacco, alcohol, or illicit drugs.  She is sexually active with 1 partner and uses oral contraceptives.  Her father died of a myocardial infarction at age 52.  Her temperature is 36.7 C (98 F), blood pressure is 110/66 mm Hg, pulse is 106/min, and respirations are 28/min.  Which of the following most likely accounts for this patient's chest pain?

Quizplus · Accepted Answer

This patient's presentation - pleuritic chest pain in the setting of a long-distance flight, hemoptysis, dyspnea, tachypnea, tachycardia, and oral contraceptive pill use - is concerning for pulmonary embolism (PE). Approximately 10% of patients with PE have occlusion of a peripheral pulmonary artery by thrombus, causing pulmonary infarction. These small peripheral thrombi are more likely to cause pleuritic chest pain and hemoptysis, due to inflammation and irritation of the lung parenchyma and adjacent visceral and parietal pleura. This patient has several risk factors for acute PE and requires diagnostic testing. CT pulmonary angiography is typically used for diagnosis in most patients. (Choice A) Primary tuberculosis usually presents with fever, weight loss, night sweats, and retrosternal chest pain (due to enlarged bronchial lymph nodes). Similarly, patients with pneumonia typically have fever (usually high-grade), chills, and cough. This patient has no such symptoms, making infection less likely. (Choice B) Ischemic chest pain is classically described as substernal squeezing or a pressure-like sensation and is not typically pleuritic in nature. (Choice C) Patients with pericarditis frequently have a history of antecedent viral infection and typically present with pleuritic chest pain that is improved with leaning forward. However, hemoptysis is not a common feature of pericarditis. (Choice D) Pulmonary artery distension can occur acutely in the setting of a PE due to a rapid increase in pulmonary artery pressure. The distension of pulmonary arteries is not thought to be a significant source of pain and would be a very unlikely cause of pleuritic pain. Educational objective: Pulmonary embolism typically presents with dyspnea, tachypnea and tachycardia. Occlusion of a peripheral pulmonary artery by thrombus may cause pulmonary infarction with pleuritic pain and hemoptysis. References: Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. (http://www.ncbi.nlm.nih.gov/pubmed/17904458)

A 34-Year-Old Woman Comes to the Physician with Dyspnea and Severe