Sudden Chest Pain Following Long-Haul Flight

Which history questions are most important to ask this patient?

• ✓A"Have you noticed any swelling or pain in either of your legs?"Reveal: My left calf has felt swollen, heavy, and sore since yesterday.Feedback: Symptoms of deep vein thrombosis often precede pulmonary embolization.
• –B"Have you had a recent high fever, productive cough, or chills?"Reveal: Nothing relevant to add.Feedback: While pneumonia causes pleuritic chest pain, the acute onset and history point elsewhere.
• ✓C"Do you take any daily medications, including hormonal contraception?"Reveal: I take a combined oral contraceptive pill every day.Feedback: Estrogen-containing contraceptives are a well-known provoked risk factor for thromboembolism.
• –D"Do you have a personal history of acid reflux or heartburn after meals?"Reveal: Nothing relevant to add.Feedback: Reflux symptoms do not explain sudden pleuritic chest pain and hypoxia.
• ✓E"Have you had any recent long-distance travel or prolonged immobility?"Reveal: I returned yesterday from a 14-hour flight.Feedback: Prolonged immobility is a major risk factor for venous thromboembolism.

Debrief · Evaluating clinical risk factors for venous thromboembolism is essential when evaluating acute pleuritic chest pain and dyspnea. Recent prolonged immobility and estrogen-containing oral contraceptives significantly heighten thrombosis risk.

Which diagnoses should remain in your working differential at this stage?

• ✓APneumothorax
• ✓BCommunity-acquired pneumonia
• ✓CAcute pericarditis
• ✓DPulmonary embolism
• –EChronic obstructive pulmonary disease exacerbationFeedback: This is inappropriate for a young non-smoker presenting with acute unilateral pleuritic pain.

Debrief · Given acute pleuritic chest pain, tachycardia, hypoxia, recent long-haul travel, and unilateral leg swelling, acute thromboembolic disease is primary, while common pleuritic etiologies like pneumothorax, pneumonia, and pericarditis should be considered.

Which diagnostic investigations should be ordered to confirm the underlying cause?

• –ABarium swallow studyReveal: Not performed in this case.Feedback: Barium swallow evaluates esophageal motility and structural lesions, which is not indicated here.
• ✓BQuantitative D-dimer assayReveal: D-dimer 2.4 mg/L FEU.Feedback: A quantitative D-dimer helps confirm fibrinolytic activity.
• ✓CCT pulmonary angiography (CTPA)Reveal: Filling defect in right lower lobe pulmonary artery on CT pulmonary angiography.Feedback: CTPA provides definitive visualization of the pulmonary arterial vasculature.
• –DHigh-resolution non-contrast chest CT (HRCT)Reveal: Not performed in this case.Feedback: Non-contrast chest imaging cannot directly visualize intravascular filling defects.

Debrief · In a patient with a high clinical pretest probability or positive biomarker screening for pulmonary vascular occlusion, CT pulmonary angiography is the definitive imaging modality.

What is the final diagnosis?

Debrief · The clinical history of prolonged immobility and combined oral contraceptive use, unilateral leg signs, hypoxemia, tachycardia, elevated D-dimer, and a filling defect in the right lower lobe pulmonary artery confirms acute pulmonary embolism.

What is the most appropriate initial management strategy for this patient?

• ✓AAdminister supplemental oxygen to correct hypoxemia
• –BAdminister immediate systemic thrombolysis with IV alteplaseharmfulFeedback: Systemic thrombolytic therapy exposes hemodynamically stable patients to an unnecessary and substantial risk of major hemorrhage.
• ✓CDiscontinue combined oral contraceptive therapy
• –DReassure patient and discharge on nonsteroidal anti-inflammatory drugs aloneFeedback: Failure to provide anticoagulation can lead to thrombus extension, recurrence, hemodynamic collapse, or death.
• ✓EInitiate therapeutic anticoagulation (e.g., low-molecular-weight heparin or DOAC)

Debrief · Therapeutic anticoagulation is the mainstay of treatment for hemodynamically stable acute pulmonary embolism. Systemic thrombolysis carries high bleeding risks and is reserved for hemodynamically unstable (massive) pulmonary embolism, and oral contraceptives must be discontinued.