A 54-year-old white male presented to the Emergency Department with complaints of progressive dyspnea and chest pain that had started simultaneously with acute onset 8 hrs before arrival.

He stated the chest pain started while going from a seated to standing position. The pain was substernal and sharp with epigastric radiation initially. The pain was also noted to be worse with movement, and although it was still present, it had subsequently waned since the initial symptom onset. His dyspnea started immediately after the onset of chest pain and was worse with exertion.

He revealed no nausea, vomiting, diarrhoea, fevers, or recent cough, as well as no similar episodes of pain or history of coronary artery disease, heart failure, chronic obstructive pulmonary disease, gastro-oesophageal reflux disease, or GI bleeding episodes.

His drug history included ibuprofen 40 TDS which he has taken routinely over the past month with food for arthritic joint pain. Of note, he had smoked a pack of cigarettes per day for the past 40 years and claimed only occasional alcohol usage.

Observations on arrival:

  • Temperature: 36.4°C

  • HR: 118

  • Sats: 86% RA

  • RR: 36

  • BP: 150/88 mmHg

The patient is then moved to the Resus area...

Q1. What would your differential diagnosis for this patient include at this stage?

Physical examination revealed an obese, ashen coloured male in obvious respiratory distress. He is alert, oriented and in obvious discomfort. His cardiovascular examination was remarkable for tachycardia, with regular and strong distal pulses in all four extremities. Pulmonary evaluation demonstrated clear breath sounds in the upper and lower lung fields, with diminished volume in the bases. His abdomen was soft and mildly distended with slight but diffuse tenderness to soft touch and percussion without tympany or guarding.

His blood results were as follows:

ABG on high flow O2:

  • pH: 7.50

  • pCO2: 3.5

  • pO2: 11.0

  • BE: -5.4

  • HCO3: 20.2

  • Lactate: 1.9

  • Hgb: 141

  • WCC: 18.2

  • Plt: 142

  • D-dimer: 0.61 (mildly positive)

  • Troponin: 60 (mildly positive)

  • U&Es and LFTs: normal

An ECG and erect CXR are performed:

Q2. Explain these investigation results and state what further investigation you might request at this stage?

Q3. Would you treat this patient for PE? Explain your answer.

Q4. Would you treat this patient for ACS? Explain your answer.

He improved immediately with high flow oxygen via a non-rebreather mask and intravenous morphine and fluids. At this stage an USS abdomen was attempted but abandoned due to poor views due to body habitus, the increased pain on palpation with probe and dyspnea when lying supine.

A CT scan was performed:

Q5. What does the CT scan show?

Q6. How would you treat this patient now?

Answer one question before attending the face-to-face teaching session. Add comments to answers already given if you think it's appropriate. The first part of teaching will be spent discussing this case:

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