Emergency Medicine Cases with Dr. Barlock
Emergency Medical Minute
Unraveling Chest Pain: A Clinical Journey
This chapter explores a patient's experience with severe chest pain, initially perceived as heartburn, leading to in-depth discussions between the patient and healthcare provider. It covers critical diagnostic tests, the consideration of rare conditions like aortic dissection, and the complexities of managing such cases. The importance of thorough imaging and careful history-taking is emphasized, illustrating the multi-faceted approach needed for effective patient evaluation and treatment.
Contributors: Travis Barlock MD, Jeffrey Olson MS4
Feel free to use the cases below for your own practice. All of the scenarios are completely made up and designed to hit several teaching points.
Case 1
25 M, presents to the ED with chest pain.
Stabbing, started a few hours ago, substernal. Thinks it is GERD.
After 2-3 minutes, pain worsens and radiates to the back.
VS: BP 125/50 (Right arm 190/110). HR 120. RR of 18. Sat 98% on RA.
Additional VS: Temp of 37.2, height of 6'5", BMI of 18.
PMH: None, doesn't see a doctor. Meds: None
FH: Weird heart thing (Mitral Valve Prolapse), weird lung thing (spontaneous pneumothorax), tall family members with long fingers and toes
Physical Exam:
Cards: Diastolic decrescendo at the RUSB, diminished S2. UE pulses are asymmetric, LE pulses are asymmetric, carotid pulses are asymmetric, BP is asymmetric
MSK: Knees, elbows, and wrists are hypermobile.
Imaging: CXR #1 normal, #2 widened mediastinum (no read yet but shows widened mediastinum), POCUS shows small effusion
CTA/MRA doesn't come back until after the case.
ECG: Sinus Tach
Labs:
NT-proBNP 500 pg/mL
D-Dimer: 7000 ng/L
CBC: Hemoglobin: 13.5 g/dL, WBC: 20,000/µL, Platelets: 250,000/µL
Chem 7: Na 138, K, 5.7, Cl 102, Bicarb 17, BUN 45, Creatinine: 3.5 mg/dL, Glucose: 180
LFTs: Albumin 2.4, Total protein 5.5, ALP: 140, AST: 3500, ALT: 2800, TBili: 3.2, DirectBili: 2.4,
Ca: 7.8
LDH: 2200
PT: 20.5, INR: 2.2, Fibrinogen: 170
5th gen High-Sensitivity Troponin: <3
Lactate: 7 mmol/L
VBG: pH 7.22, paCO2 28, bicarb 15
Notes: Can have patient crash somewhere in middle and show 2nd xray
Case 2:
A 67-year-old female is brought to the ED by her daughter due to progressive weakness, confusion, and fatigue that have worsened over the past week.
Unable to get out of bed and has become increasingly lethargic. Also having some nausea, constipation. The daughter denies any preceding illness, recent trauma, or travel. Does not know her meds but will head home to get them after talking with you.
VS: BP 88/55 mmHg, HR 110, RR 20, O2 Sat 98% on room air.
Additional VS: Temp 36.8°C.
PMH: Hypertension, osteoarthritis, and depression.
Physical exam:
General: Thin, somnolent but arousable.
HENT: Dry mucous membranes
Neuro: Confused, A&Ox1 (self), hyporeflexia
Labs (Includes many that would not return in the ED in case you want to take this case forward to the floor)
CBC: WBC 9,500, Hb 16.5, Hct: 50%, Platelets 220,000
Chem7: Na 129, K 2.1, Cl 95, HCO3 34, Creatinine 1.6, BUN 40, Glucose 115
LFTs: normal
Magnesium: 1.1
Calcium: 10.8 mg/dL (corrects to 12.8)
iCal: 3.2
Phosphate: 2.3 mg/dL
Albumin: 2
BUN:Cr ratio: 25
VBG: pH: 7.49, PaCO2 45, HCO3: 34
Lactate: 2.8
Serum Osmolality: 276 mOsm/kg (Osmolal gap of 2)
Urine Osmolality: 550 mOsm/kg
Urine Sodium (UNa): 10 mEq/L (low). Urine Potassium (UK): 25 mEq/L (elevated). Urine Chloride (UCl): 12 mEq/L (low). Urine Magnesium (UMg): 20 (Elevated). Urine Calcium (UCa): 50 in 24 hrs (Low)
100 cc of urine with foley
FeNa
Plasma renin activity: 15 mg/mL/hr (elevated), Aldosterone: 25 ng/dL (Elevated), ADH: Elevated, Diuretic screen: Positive for thiazides
PTH: 8 (low), HsTrop: 32, Cortisol and ACTH: Normal.
EKG: Hypokalemia features
CXR: Normal
Renal US: shows stones
Improves with fluids
Note: Can have daughter return with med list at some point including HCTZ, ibuprofen, and sertraline
Case 3:
Patient Presentation
EMS Report: A 27-year-old male involved in a high-speed motorcycle collision is brought to the emergency department by EMS. The patient was found unconscious at the scene with evidence of severe thoracic and extremity trauma. He was intubated en route for airway protection due to altered mental status (GCS 7).
VS: HR 130, BP 90/60, RR: bagging at 12 bpm, satting 88% on 100% FiO2
Primary Survey
Airway: Endotracheal tube in place.
Breathing: Decreased breath sounds on the left side with visible chest asymmetry and paradoxical chest wall movement.
Circulation: Mottled extremities noted, with significant deformity of the right thigh. Pulses are diminished in the right leg
Disability: GCS remains 7 (E1 V2 M4). Pupils equal and reactive.
Exposure: Full-body examination reveals an open fracture of the right femur, multiple abrasions, and bruising over the chest wall.
Vent alarms
Peak Inspiratory Pressure (PIP) 40 cm H₂O (elevated)
Plateau Pressure (Pplat) 35 cm H₂O (elevated)
EtCO₂ (End-Tidal CO₂) 55 mmHg
High-Pressure Alarm Triggering frequently
Glucose 120
CBC: Hgb 8.9, Hct 27, WBC 14.2, platelets 220,000
VBG: pH 7.28, pCO2 33, bicarb 18, lactate 4.5
CXR with tension pneumothorax
Patient improves after chest tube, pigtail catheter, or needle decompression.
Ready to be transferred upstairs and O2 starts tanking again
Vent alarms- second episode
Peak Inspiratory Pressure (PIP) 35 cm H₂O (elevated)
Plateau Pressure (Pplat) 30 cm H₂O (elevated)
EtCO₂ (End-Tidal CO₂) 20 mmHg
HR: 140, satting 84%, temp 38.5,
ABG: pH 7.32, pCO₂ 30 mmHg, pO₂ 60 mmHg on 100% FiO₂, HCO₃⁻ 18 mmol/L (hypoxemia and metabolic acidosis).
D-dimer: Elevated
Thrombocytopenia: Platelets 90,000/µL.
US shows blown right ventricle
ECG shows new RBBB
CT PE: Ground glass opacities, consolidation, centrilobular nodules, septal thickening, and fat-attenuating lesions.
Note: Management is largely supportive care so once the diagnosis is made, end the case.
References
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Palmer BF. Metabolic complications associated with use of diuretics. Semin Nephrol. 2011 Nov;31(6):542-52. doi: 10.1016/j.semnephrol.2011.09.009. PMID: 22099511.
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Reed MJ. Diagnosis and management of acute aortic dissection in the emergency department. Br J Hosp Med (Lond). 2024 Apr 30;85(4):1-9. doi: 10.12968/hmed.2023.0366. PMID: 38708978.
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Roberts DJ, Leigh-Smith S, Faris PD, Blackmore C, Ball CG, Robertson HL, Dixon E, James MT, Kirkpatrick AW, Kortbeek JB, Stelfox HT. Clinical Presentation of Patients With Tension Pneumothorax: A Systematic Review. Ann Surg. 2015 Jun;261(6):1068-78. doi: 10.1097/SLA.0000000000001073. PMID: 25563887.
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Rothberg DL, Makarewich CA. Fat Embolism and Fat Embolism Syndrome. J Am Acad Orthop Surg. 2019 Apr 15;27(8):e346-e355. doi: 10.5435/JAAOS-D-17-00571. PMID: 30958807.
Produced by Jeffrey Olson, MS4
Special thanks to Evan Fisch MD
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