Jan's chest pain

I was working the morning urgent care clinic, rather annoyed at how tightly things had been scheduled. But there is nothing I can do about being 1-1/2 hours behind. I'm just going to have to deal with it.

In room 18, Jan, age 52, is sitting on the exam table. Her husband Evan sits attentively in the chair next to her. She is here because of chest pain. I'm on my guard knowing chest pain can present a number of traps for the primary care physician. A host of serious conditions can masquerade as commonplace muscular strains or joint problems. Now she has my full attention and any distraction I had about the overscheduling is gone.

Jan first noticed chest pain about 2 weeks ago. It's located just to the left of the breastbone and goes through to her shoulder blade. She thinks it's related to some painting and yard work she was doing a few months ago. In fact her husband, taking charge at this point, assures me that it is a very muscular kind of pain, and he is sure she does not have heart pain. Jan does have a history of heart disease, having received a stent two years ago. Just 6 months ago she was examined by Dr Q, the cardiologist, and found to have pristine arteries on cardiac catheterization. Evan makes clear, their son is arriving within the hour from basic training, and they are intent on seeing him.

There's not much remarkable on Jan's exam. Her chest wall is not tender anywhere. The shoulder exam doesn't reproduce the pain. The heart and lung exams are normal. The right leg shows some varicose veins, but I can't reproduce any tenderness with pressure over the calf. The only slight abnormality -- oxygen saturation at 95% -- a little low for a non smoker.

Every physician has been lectured about this type of patient-- it's engraved in our memories with the admonition, "do not miss a pulmonary embolism", a blood clot that has arisen from the legs and lodged in the arteries to the lungs from the heart. The story is perfect -- leg pain, chest pain, a little short of breath.

Jan, I think you need to go to the hospital, I say. Turning to her husband, who looks a little uncomfortable. I can see their plans melting away and hours of emergency room evaluation looming ahead. I know it's difficult to interrupt your plans, I explain, but a blood clot to the lungs would be extremely dangerous. It can result in sudden death. I can't agree with you going home or giving it time. Anything other than going directly to the hospital would be like playing Russian roulette. I don't like to pull out the "death" card frequently. It's the atom bomb of medical advice.

Jan accepted my recommendation, and the couple headed down to the hospital. I called report into the hospital, waiting to hear what would be found.

About 3 hours later, I received the call. You were right, Jan has multible pulmonary emboli. 3 in the right lung and 2 in the left lung. She is being admitted for treatment and monitoring. I'm thankful that my annoyance at the scheduling snafus did not result in a superficial encounter and a missed diagnosis.