B (3:01)

That's a really good point about illness scripts. And I think especially in training, we're kind of susceptible to these biases because we do so much board studying. And I think the way that we're taught to study for boards is with certain associations, like you said, or extreme manifestations of diseases that will often present more subtly in real life. So, Dr. Cherub, why don't you take us into the case?

C (3:20)

I'll try to describe it sort of in real time. I received a phone call early one morning from a 43 year old male patient of mine and he was complaining of two days of severe right back and shoulder pain. And he said that this pain had persisted despite his taking NSAIDs. And he asked what I thought he should do and fortunately I was in the office that day and I told him to come in to see me. I think if, if it were the weekend, I probably would have sent him to the emergency room simply because of the severe nature of his right sided pain. So as I said, the patient is 43 years old and he was well until two days ago when he suddenly developed chest and right shoulder pain. It began several hours after a prolonged training session in which the the patient did both running and weightlifting. He states that at that time he lifted more weights than usual. The pain didn't develop right after the exercise, but when he got home he noticed that he developed this pain and when he tried to go to sleep he felt the pain was getting worse and worse. So that's when he started non steroidal anti inflammatories and his wife had some acetaminophen and codeine at home. And although it provided some relief, it didn't eliminate the pain entirely. Despite the pain, however, the next day he tried to go out running, but he felt limited by the pain, which he said tended to increase when he took a deep breath. It also worsened when he was lying down on his right side. It was not associated with cough or fever or shortness of breath.

B (4:59)

Any past medical history on this 43 year old gentleman?

C (5:02)

Okay, he had hand surgery and arthroscopic surgery sometime in the distant past. He had a history of kidney stones, in fact several months earlier and it was on the left side. It got better with fluids and when they did a CT of his abdomen and pelvis. They noticed that there was a tiny stone on the left, but there was nothing on the right. And the pain abated even though he didn't find the stone. And that was again several months ago. That's pretty much in terms of his past history. His family history was really unremarkable.

B (5:32)

Does he take any medications?

C (5:34)

He took finasteride for male pattern baldness, but he wasn't taking any other medications. He was a very healthy guy. You know, a guy who works out multiple times a week.

B (5:44)

So where's your thinking at this point? Have you narrowed your differential diagnosis or is it still pretty broad?

C (5:49)

I thought he had muscular skeletal pain. I thought it was either a muscle strain or perhaps he had a rib fracture from the exercise. I thought about a recurrent stone, but I thought that was unlikely because he had no stones on the right, he only had a stone on the left, and it was only months earlier. So my sense was this was muscular skeletal pain. In an otherwise healthy young man, that.

B (6:10)

Seems like the most likely situation. So he comes into your office. What are his vitals and what does his exam look like?

C (6:16)

Well, first of all, he looked incredibly healthy. His pulse was 60. His blood pressure was 115 over 80. Respiratory rate was normal. O2 sat was 97%. He had no neck vein distension, no thyromegaly. When I examined his chest, though, I. I noticed that there was slight dullness, dullness to percussion, and decreased breath sounds at the right base. I went and examined him again and I found that those findings were still there. That was a bit of a surprise to me. And he also had CVA tenderness, literally touching him on his right side of his chest. Posteriorly, he had significant discomfort. The cardiac exam was totally normal. He had a normal S1 and S2. I didn't appreciate a murmur. He had no peripheral edema. His abdomen was soft, non tender. There was no organomas. So really a relatively normal exam. Except for the fact, you know, when he moved around, you could tell that he was in some discomfort. Yeah, I was surprised about the breath sounds. Right. It was certainly consistent with the pleural effusion. Clearly, nephrolithiasis wasn't going to do that. And so I thought, well, you know, could this be a hemothorax? He said he was lifting more weights. There wasn't a clear cut indication that there was trauma, but there was also nothing to suggest that he had an infectious or an inflammatory process going on. I mean, he had no fever, no chill. He didn't have a cough. So I was in a sort of a quandary about why he had this finding on physical exam.

B (7:44)

So already we can see the benefit of a very thorough physical exam, which I know not everyone takes the time to do. And something that can, you know, easily be missed is decreased breath sounds at the base. This actually might end up being a major clue to his diagnosis. So what were your next steps?

C (8:00)

So I'm in the office. Remember, I'm not in the hospital. I was able to get an EKG and it showed normal sinus rhythm, normal intervals, normal axis. I was able to do a urinalysis. He didn't have any blood in his urine, so it made it unlikely that this was a stone. And of course, I ordered a chest X ray either to confirm or refute my findings on physical exam. And the X ray showed a small right pleural effusion. And there was some atelectasis above the pleural effusion. It was very difficult to tell whether it was atelectasis or an infiltrate. I really couldn't evaluate the ribs on that film. It's conceivable there could have been a fracture, but I didn't think that that was likely. So, you know, I'm in the office and other patients are waiting. So the question is, you know, what do you do now? I clearly thought that he needed more imaging, right, because of the findings on the chest X ray. And I was faced with a situation where I knew I should order a ct, but the question is whether I should order a CT PE study. And, you know, there was very little to suggest pulmonary embolism. Right. He had no dyspnea, he wasn't hypoxic, he wasn't tachycardic, he wasn't tachypneic. But I, I did know that pleural effusions are relatively common in, in patients with pulmonary emboli. They occur into 20 and 40% of patients who have pulmonary embolic disease. I know that most of you there would say, well, you know, why don't you order a D dimer? And, you know, I'm in the office, I know I can get a CT rapidly. The D dimer is going to take a while. If I' for a ct, I thought I should send him down for a CT PE study despite the fact that his Wells score was zero. In fact, any scale you look for pulmonary embolic disease, he was at very, very low risk. And D dimer might have helped. I didn't do it.

B (9:49)

Just a note to say you know, we always learn that there's a certain sequence of events that we should go through before imaging a patient, for example. But it completely depends on the hospital versus the clinic setting, what resources you have available to you, et cetera. And it sounds like there was something in his story that was maybe just sounding alarms a little bit for you and made this patient feel a little bit more urgent than maybe a different patient might have felt.

C (10:13)

Yeah, I think you're right. I think there was something unusual about this patient. There was an interesting interaction that followed. The patient's wife was a physician's assistant at another hospital, and he said, I'll go ahead and do this study, but you need to call my wife and tell her about it. So when I. I called his wife, she responded by saying that my. My husband is healthy. He has no risk factors for pulmonary embolic disease. He doesn't have a clinical picture that's consistent with that diagnosis. And I said, I agree. I said, but it's also a diagnosis that I really don't want to miss, and I don't think it's a harmful procedure, and it'll give us a lot more information. And finally, she sort of acquiesced and allowed me to do it.

B (10:55)

So what did the CTPE show?

C (10:57)

Yeah, so I got, you know, an hour later, I got a phone call from the radiologist. That always a bad sign. And it showed multiple central filling defects were seen in the right lower lobe of the pulmonary arteries, including the basal segment and the segmental branches, consistent with acute pulmonary emboli. There was also a pulmonary embolism in the left lower lobe, segmental pulmonary artery extending to the subsegmental branches. Examination of the heart showed that he had no right heart strain. The lungs showed a ground glass opacity in the basilar part of the right lower lobe, which the radiologist thought was consistent with a pulmonary infarct. And so. And then I thought, well, maybe the pain was really from. From the infarct.

B (11:40)

This is a lot to manage in the outpatient setting. So what did you do for him?

C (11:45)

I could have sent him home on an anticoagulant, but he was in such severe pain at this point, you know, it was two hours into the visit, so sent him to the emergency room, where they were able to treat his pain. They also got a Doppler there, which didn't show any thrombus in his lower extremities. Eventually, I sent him for a thrombophilia workup, and he was heterozygous for the factor V Leiden mutation, which puts him at slightly increased for pulmonary embolic disease. But the hematologist said that he needed to be on anticoagulation for a long period of time because he viewed it as an idiopathic pulmonary embolism. And although the factor V Leiden may have been partially to blame, maybe there was some as yet undiagnosed thrombophilic element that caused him to have this pulmonary embolic disease. You know, he wasn't. There was no long airplane trip, car ride. He had no comorbidities to suggest that we predispose him to a pulmonary embolic disease. You know, I'll be honest. I. I had no idea what this patient had, and I just. It was my clinical judgment that an unexplained pleural effusion needs further evaluation. I think that there were several points that were helpful after seeing this patient. One is that pleural effusions are very common in pulmonary embolic disease. They tend to be small. D dimers are important to make a diagnosis of pulmonary embolism, and I certainly didn't do it, but I certainly would think that it's an important adjunct, particularly when there's a question about the likelihood of a pulmonary embolism. And thirdly, that young patients who have pulmonary emboli tend to have fewer symptoms of pulmonary embolic disease. You know, when we're in the hospital, we see patients who present with catastrophic pulmonary emboli. They almost always are short of breath, frequently they're hemodynamically compromised. But here was a man who had multiple pulmonary emboli. No dyspnea and only pleuritic chest pain. And I think the pulmonary infarction was causing his pain. And when you look at the literature on pulmonary infarctions, they frequently, in young patients present as severe pleuritic chest pain in the absence of dyspnea. And they're frequently thought to be muscular skeletal. As I thought about this patient initially, and again, I think I want to make a statement about the physical exam here. I think if I hadn't picked up that there was a possible pleural effusion, I may have just ordered a CT scan, or I may not have ordered anything or just given him more, more analges with the assumption that this was muscular skeletal, because in reality, that's what I thought he had. Right. And it was only the physical exam that made me think that was less likely. You know, it was certainly an edifying experience for me.

B (14:30)

Super interesting case. Young, healthy guy, goes to the gym, works Out a little harder than usual, has some shoulder and back pain, and then ends up on a doac, maybe for the rest of his life. This is definitely the kind of case that stays with you. I will admit I would not have associated pleural effusion with PE. It's interesting that up to 40% of those cases can co occur. So I think that's a really good learning point as well.

C (14:53)

In my review of young patients with pulmonary embolic disease, A significant percentage, 60% of those patients, lacked any cardiopulmonary abnormalities or DVTS. This is at least twice the frequency of that found in older group. Similarly, 70% of younger patients with PE were not tachycardic, while over 80% of older patients were tachycardia. Physical examinations in younger patients tended to be normal, much more commonly than older patients. 20% of younger patients with PE totally had pleuritic chest pain as their symptomatology for pulmonary embolic disease. So illness scripts are helpful, but the clinical context in which they occur is helpful. I'm in an outpatient setting. Clearly, the patient wasn't hemodynamically compromised when he came in. He wasn't short of breath because both of those things would have led him to come to the emergency room. But he thought, as did I, that this was probably muscular skeletal, but it turned out to be a lot more serious.

B (15:55)

Absolutely. So don't be fooled by the younger age. And beyond that, maybe even think a little bit harder. I'm actually thinking about how we think about anginal symptoms in certain populations, like women or diabetic patients, how they just present completely differently. I think it's interesting to think about the way that younger patients present in conditions like pe, where you need to keep your index of suspicion very high.

C (16:15)

Yes. And you need to be able to do a good physical exam.

B (16:18)

Absolutely. Never lose the art of the physical exam.

C (16:21)

Please don't do that.

B (16:23)

Well, this has been a really interesting case, Dr. Cherub. Thank you so much for sharing it with us. It actually is a great complement to a recent episode that we did earlier this year on pulmonary embolism. So very good timing. It's been wonderful having you with us and having you share your expertise, and we'd love to have you back again soon.

C (16:39)

Thank you. My pleasure.

A (16:53)

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