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INSTRUCTION

This patient presented with sudden onset of lateral chest pain aggravated by deep inspiration and coughing. Listen to this patient'schest. Examine her chest.

SALIENT FEATURES

History

• Sharp localized pain worse on coughing or deep respiration.

• Nature of the sputum (purulent expectoration in a patient with chest infection, haemoptysis in puhnonary embolism).

• Drug history (oral contraceptives).

Examination

Pleural rub (superficial, scratchy, grating sound heard on deep inspiration).

Proceed as follows:

• D~tlerentiate between pleural rub and crackles by asking the patient to cough and check whether or not there is any change inthe nature. (Note. No change with the pleural rub.)

• Tell the examiner that you would like to listen for tachycardia and right ven-tricular gallop (pulmonary embolism).

DIAGNOSIS

This patient has a pleural rub (lesion) which is caused by either underlying infection or pulmonary embolism (aetiology). You wouldlike to analyse blood gases to determine whether she is hypoxic (functional status).

QUESTION

SHow would you investigate this patient?

• Full blood count.

• Sputum cultures.

• Blood gases.

• ECG.

• CXR.

• Ventilation-perfusion scan.

ADVANCED-LEVEL QUESTIONS

What would you expect to see in the ventilation-perfusion scan in a patient with pulmonary embolism?

In acute pulmonary embolism the area of decreased perfusion usually has normal ventilation, whereas in pneumonia there areabnormalities in both the ventilation and perfusion scan.

How would you treat a patient with pulmonary embolism?

• Initially with heparin and then with oral anticoagulants for at least 3 months.

• Pain relief for pleurisy.

What are the ECG changes in pulmonary embolism?

These include:

• Sinus tachycardia.

• Tall R wave in lead VI.· SI, S2, S3 syndrome (S waves in limb leads I, II and III).

• S 1, Q3, T3 syndrome (S in limb lead I and Q wave and inverted T wave in limb lead III).