Respiratory: chest pain

Kathryn is a 20 year old English Literature student at university. She suddenly experiences sharp chest pain and comes to A&E where she is seen by the SHO. She says that she suddenly developed chest pain whilst watching TV. She describes sharp chest pain which is worse with taking deep breaths. What is this type of chest pain called?

She is also feeling short of breath, but thinks this may be due to the pain that she has when breathing. She is currently not taking any medications apart from the pill. Since heading to the hospital she has also coughed up a small amount of bright red blood. What is the medical term for coughing up blood?

On examination her vitals are normal, and respiratory examination reveals nothing abnormal. However, the SHO notices that her right calf is swollen, tender and red. What has happened to her leg?

Based on the diagnosis of her leg condition the SHO can now figure out the diagnosis. What is the respiratory condition which Kathryn has?

What risk factors increase the chance of this condition?

Male

Female

Progesterone-only pill

Combined oral contraceptive pill

Recent immobilisation

Recent heavy exercise

Recent surgery

Dehydration

Malignancy

What would be the most appropriate way of confirming the respiratory diagnosis?

D-dimer blood test

Doppler scan of her leg veins

Chest X-ray

CT pulmonary angiogram (CTPA)

She is started on therapeutic low-molecular weight heparin to treat the current condition, and after confirmation by the investigation she is started on warfarin for 6 weeks. What does Kathryn need to know about warfarin and heparin? Sort out the properties of warfarin and heparin.

Warfarin

Heparin

To sort

Reversed by giving vitamin K, fresh frozen plasma or prothrombin complex concentrates
Is taken as a tablet
Acts on the intrinsic pathway of coagulation
Works by inhibiting vitamin K reductase, necessary for clotting factors 10, 9, 7 and 2.
Acts on the extrinsic pathway of coagulation
Is potentiated by alcohol
Reversed using protamine sulphate
Is given as an injection
Causes problems in pregnancy
Monitored by activated partial thromboplastin time (APTT)
Acts on anti-thrombin III
Monitored by measuring the prothrombin time (which is standardised as INR)

After being admitted for several hours (mostly waiting for the investigation to be done), she admits that she thinks that it is odd that she developed this condition, and she asks if there are any underlying problems that could have set it off?

Kathryn is discharged later that day, not too happy about having to take warfarin and attend the anticoagulation clinic (which involves blood tests of which she is not keen on), and to make matters worse she has to see the GP about alternative contraceptive measures. What would be the best contraceptive option to advice to Kathryn?

Continue on combined oral contraceptive pill

Switch to progesterone only pill, injection or implant

Switch to barrier contraceptives only

Advise abstinence

Kathryn is discharged and lives happily ever after as the GP appropriately manages her contraceptives whilst the anticoagulation clinic vigilantly monitors her INR and warfarin dosing. She also saves a bundle as she is unable to drink.

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DVT

Association between DVT and PE.

CTPA

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