Chief Complaints From The Community Hospital Blog 1
This is the first entry in Chief complaints From The Community Hospital. We are the Emergency Medicine Residency program of St. Mary Mercy Hospital in Livonia, MI just outside of Detroit. We are a level 2 trauma center with an annual census of 51,000. This will be a monthly series of interesting case reports from our ED.
Our first case presents with a chief complaint of bilateral jaw pain.
For the laypeople and those who are early on in their medical education, it’s always a good idea to think about what can cause something like jaw pain. Remember that common things happen commonly. When you first hear of an early 30s person with jaw pain you should think about something along the lines of a tooth problem or an earache. These are going to be your common causes of this complaint. As ER doctors it’s our job to rule out the badness. Our entire residency is spent teaching us to think about the scary things that cause these complaints and how to decide who needs what workup based on their presentation, history and physical exam. Remember, this is an interesting cases blog so you can probably assume this wasn’t a case of bad cavities.
The patient was a 31-year-old woman with a history of remote nephrectomy. Her pain began approximately 2 hours prior to her presentation. She describes the pain as sharp and on both sides. Initially, the patient had some sweating and dizziness that lasted for a few minutes but quickly went away. She complained that the pain in her jaw is worse when she coughs. She’s been battling a cold for the past few days and has been having some cough, sore throat and nasal congestion. Despite her doctor’s recommendation she continues to smoke a pack of cigarettes daily.
After taking a history it’s important to do a thorough but focused physical exam. Teaching point number one is that you should start with your vital signs. As our program director loves to say, vitals are vital.
On arrival to the ER, the patient’s vitals were only abnormal for a high blood pressure of 160/80. The patient appeared well. The patient’s physical exam was unremarkable, the lungs were clear, the heart was normal without any extra sounds. The patient had good dentition without any obvious cavities or pain when her teeth were pushed on. Her ears were clear without any sign of infection. Given the complaint of jaw pain, a cardiac workup was begun.
While waiting for the results of the testing the patient remained well, however, the pain in her jaw continued. The labs came back and the troponin, a test for whether your heart is being damaged, was negative. All of the electrolytes in the patient’s blood were normal. The EKG was normal. The EKG showed normal sinus rhythm with normal intervals and no acute ischemic changes, which is to say it didn’t show any kind of ongoing heart attack. A chest Xray was performed and was read as normal. There were no obvious cases of pneumonia or fluid around the lungs.
At this point, the resident on the case reviewed the images herself. This is teaching point number 2, always look at your images. This is admittedly difficult especially when it’s a busy day in the ER but at the end of the day, you’re responsible for the interpretation of the images as much as the radiologist. On the resident’s look at the chest x-ray, she noted that the cardiopulmonary silhouette, the heart and lung shadows, looked a little bit wide in the middle. Lots of things can cause this, from the way the x-ray is taken to something bad like your aorta rupturing.
Teaching point number 3, reevaluate your patients. At this point in the visit, the patient has a negative set of labs, a negative EKG and a negative chest x-ray as read by the radiologist. The resident was slightly suspicious about the chest x-ray being a little bit abnormal so she went back in to talk to the patient. When she got into the patient’s room she started to ask about the pain that the patient was having and how it all started. She asked more about the sharp pain that the patient was having and had her further describe it. The patient was prompted with words like “electricity”, “heaviness”, and “tearing”. Upon hearing that last word the patient said, “oh yeah it feels like it’s tearing in my chest up into my jaw”.
As you can imagine this is not what the ER doctors want to hear. A tearing sensation in the chest is concerning for a lot of reasons, chief among them it’s what people whose aorta’s are dissecting typically describe. For obvious reasons, the patient was immediately taken over to CAT scan. The patient has contrast dye injected into her veins and a scan of her chest was timed and performed when the dye would be in her arteries. The CT scan showed a Stanford Type A aortic dissection originating at the aortic root and measuring up to 7.2 cm to the level of the right pulmonary artery. The dissection flap extended to the left subclavian artery. There was also some hyperdense material in the mediastinum concerning for blood products.
For the lay people and early learners, this is not great news. There are different types of aortic dissections. Most commonly we speak of either Stanford type A or B and DeBakey classifications. Stanford is easier so I’ll stick with that here for you. A type A dissection involves the aortic arch, the part of the big blood vessel that pumps blood to your body directly off of your heart. A type B does not involve the arch. This patient had a type A.
This is neither here nor there but you should read about Dr. DeBakey. He is the father of modern cardiovascular surgery, he named the dissections after himself, eventually suffered from one and survived the operation he devised to repair it, he also was involved in developing MASH units and he started what eventually became the VA hospital system.
As an ER doctor, your job is to prevent secondary injury. We can’t make you unfall down, we can’t make your aorta undissect, our job is to prevent what comes from those injuries. The patient’s blood pressure was high and this is a bad thing. High blood pressure increases the pressure on the part of the aorta that is being pulled off the wall and can cause it to extend farther and farther down the pipe. For this reason, we give medications to lower the patient’s blood pressure. For those of you in med school and residency, remember that we give the beta blocker first because it will prevent reflex tachycardia when you give the nitro based medication. Tachycardia means that the heart beats fast and this too can worsen the aortic dissection. The patient in this story has a happy ending. She was started on the medications and got to take a helicopter ride to one of our affiliated hospitals to have her aorta repaired. She did well after the surgery.
So here are some takeaways.
Common things happen commonly but at the same time, it doesn’t mean every common complaint has a common cause. As an ER doctor, your job is to rule out badness.
Aortic dissection, in particular, is a difficult thing to diagnose. It is frequently missed especially in atypical patients, like 31-year-old relatively healthy women. It also has a very high mortality rate. It is frequently fatal. It is sometimes referred to as “the great masquerader” as it can present in many different ways from a tightness in the chest similar to a heart attack to blood in your urine like a kidney stone. Whenever you see a patient with complaints in multiple organ systems consistent with an ischemic injury you should consider dissection.
One study showed that if a patient has these 3 things their chance of having a dissection was 100%. Mediastinal widening/aortic widening on chest x-ray, tearing back in the chest radiating to the back, and pulse differentials. If you have one of these you have a 39% chance of having a dissection. Two of these confers an 83% chance of having a dissection and all 3 gives a 100% chance.
At the end of the day always trust your gut and rule out the badness.
Residents: Dr. Timothy Hanley and Dr. Lauren Robinson
Attending: Dr. Hope Ring