A 19-year-old female presents with sharp right flank pain and shortness of breath

by Stacey Chamberlain

A 19-year-old female presents with sharp right flank pain and shortness of breath that started suddenly the day prior to arrival. The pain is worse with deep inspiration but not related to exertion and not relieved with ibuprofen. She denies anterior chest pain, cough, and fever. She denies leg pain or swelling and recent travel, immobilization, trauma, or surgery. She has no anterior abdominal pain, no dysuria or hematuria and no personal or family history of gallstones, kidney stones, or blood clots. She’s never had this pain before, has no significant past medical history and her only medication is birth control pills. On exam, her vital signs are within normal range, she has normal cardiac and pulmonary exams, no costovertebral angle tenderness, no chest wall or abdominal tenderness and no leg swelling.

Do you need to do any studies to evaluate this patient for a pulmonary embolism?

Pulmonary Embolism Rule-Out Criteria (PERC)

  • Age ≥ 50
  • Heart rate ≥ 100
  • O2 sat on room air < 95%
  • Prior history of venous thromboembolism
  • Trauma or surgery within 4 weeks
  • Hemoptysis
  • Exogenous estrogen
  • Unilateral leg swelling

The PERC CDR was originally derived and validated in 2004 and with a subsequent multi-study center validation in 2008. In the larger validation study, the rule was only to be applied in those patients with a pre-test probability of < 15%, therefore incorporating clinical gestalt prior to using the rule. PERC is a one-way rule, as mentioned above, which tried to identify patients who are so low-risk for pulmonary embolism (PE) as to not require any testing. It does not imply that testing should be done for patients who do not meet criteria, and it is not meant for risk stratification, as opposed to the Wells’ and Geneva scores.

Case Discussion

In order to apply the PERC CDR to the case study patient, the ED physician pre-supposes a pre-test probability of < 15%. If the ED physician has a higher pre-test probability than that, he/she should not use the PERC CDR. If the ED physician, in this case, did indeed have a pre-test probability of < 15%, the case study patient would fail the rule-out due to her use of oral contraceptives. In that case, the ED physician would need to determine if he/she would do further testing which could include a D-dimer, CT chest with contrast, ventilation/perfusion scan, or lower extremity Doppler studies to evaluate for deep vein thromboses (DVTs). The PERC CDR gives no guidance in this case.

Cite this article as: iEM Education Project Team, "A 19-year-old female presents with sharp right flank pain and shortness of breath," in International Emergency Medicine Education Project, June 17, 2019, https://iem-student.org/2019/06/17/a-19-year-old-female-presents-with-sharp-right-flank-pain-and-shortness-of-breath/, date accessed: October 16, 2019

Bat Sign

Dear students/interns, learn ultrasonographic anatomy and clinical ultrasound basics to improve your decision making processes.

bat2

The bat sign is critical for correct identification of the pleural line. Always begin lung ultrasound by identifying the bat sign before proceeding to look for artifacts and pathologies.

This sign is formed when scanning across 2 ribs with the intervening intercostal space.

The wings are formed by the 2 ribs, casting an acoustic shadow. The body is the first continuous horizontal hyperechoic line that starts below one rib and extends all the way to the other. (see above video) The body is the pleural line, i.e., parietal pleural. Normally, the pleural line is opposed to and hence indistinguishable from the lung line (formed by the visceral pleura).

To learn more about it, read chapter below.

Read "Blue Protocol" Chapter

Need a chest tube or not?

420 - right pneumothorax1

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

What is wrong with this CT?

In case you didn’t encounter shortness of breath today!

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

Chest X-ray Interpretation, No Worries!

336.4 - normal PA chest x-ray - BONY STRUCTURES

How to read a chest x-ray chapter written by Ozlem Koksal from Turkey is just uploaded to the Website! For pathologic images, please visit our Flickr channel – Chest Images and Videos Album.

Sudden Shortness of Breath

In case you didn’t encounter a sudden shortness of breath today!

A 23-year-old male patient presented with sudden onset SOB and chest pain. BP: 121/68 mmHg, HR: 102 bpm, RR: 22/min, T: 37, SpO2: 93% in room air. He has no history of disease. On the exam, you appreciated a decreased breath sound on the left and checked the thorax with bedside ultrasound. Here are the ultrasound findings of the patient.

What is your next action?

624.5 - Figure 5_Lung Point on M Mode

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

Assessing Pneumothorax Size

Selected Pulmonary Emergencies

Pulmonary/Respiratory Emergencies selected from SAEM and IFEM undergraduate curriculum are uploaded into the website. You can read, all these chapters freely. More specific disease entities are on the way.

Asthma

by Ayse Ece Akceylan Case Presentation A 50-year-old male with a history of asthma presents to the emergency department (ED) with shortness of breath, tachypnea,

Read More »

Chronic Obstructive Pulmonary Disease (COPD)

by Ramin Tabatabai, David Hoffman, and Tiffany Abramson Case Presentation A 68-year-old male presents to the emergency department (ED) with audible wheezing, and he is

Read More »

Pneumonia

by Mary J. O. Case Presentation A 74-year-old male with a history of hypertension and diabetes presented to the emergency department with a cough productive

Read More »

Spontaneous Pneumothorax

by Mahmoud Aljufaili Introduction Pneumothorax refers to the presence of air in the pleural cavity. It can impair oxygenation/ventilation. There are two types of spontaneous pneumothorax

Read More »

Do you need more?

Pneumonia is just uploaded!

377.1 - pneumonia1

Pneumonia chapter written by Mary J O from USA is just uploaded to the Website!

Asthma is just uploaded!

Inhaler

Asthma chapter written by Ayse Ece Akceylan from Turkey is just uploaded to the Website!

A 68-year-old with wheezing

copd

Chronic Obstructive Pulmonary Disease (COPD)

by Ramin Tabatabai, David Hoffman, and Tiffany Abramson, USA

A 68-year-old male presents to the emergency department (ED) with audible wheezing, and he is in severe respiratory distress. He is speaking in 2-3 word sentences, and he is diaphoretic and slightly confused. Per the paramedic report, the patient is a two pack per day smoker. On physical examination, the patient demonstrates poor air movement, and you note that he has a “barrel chest.” As you pick up the phone to call the respiratory therapist for airway management, you wonder, “What other interventions should I initiate and are there other diagnoses I should be considering?”

What is the value of BiPAP on COPD?

Touch Me

BiPAP on COPD

The use of BiPAP led to decreased mortality (NNT=10), reduction in treatment failure (NNT=5) and decreased need for intubation (NNT=4).
Answer