You return to the ED at 7am to find the night doc repairing a complex upper extremity laceration. Evidently,it was a hectic night, but your colleague insists on finishing the repair he started three hours earlier. Sign out will wait. There are three charts in your rack. You scan the triage notes:

"32-year-old man with asthma exacerbation, dyspnea, and chest pain- albuterol nebs and prednisone ordered." Next, "28-year-old female with chest pain and dyspnea." Third, "62-year-old male with upper back pain." His ECG is non diagnostic but the blood pressure of 200/120 piques your interest and guides you to his room. This hypertensive one hour prior to arrival; when he describes the pain as ripping, you consider an aortic emergency...

A request for an analgesia order prompts you to see the 28-year-old female next. She report abrupt onset of severe pleuritic left chest pain while breast feeding her 4-day-old daughter delivered by c- section. The pain has been constant since it began two hours ago and is accompanied by dyspnea and non productive cough. She appears tachypneic and apprehensive. The lungs are clear. She attributes mild legs swelling to pregnancy...

From behind a curtain you hear the asthmatic insisting he has to leave for work. He's a 32-year-old male "frequent-flier" asthmatic well known to the ED staff. Seeing his face, you realize you've intubated him before but the appears quite comfortable as he starts his third neb. He'd been battling this exacerbation all night but called 911 when his inhaler ran dry. The chest tightness referred to an the triage note resolved with the first treatment. He denies any infectious symptoms. The lung exam reveals equal breath sounds with good air exchange and minimal expiratory wheezing. The nurse asks if you want a chest x-ray...

Just as you think you have the department under control, you are notified that the clinic is sending a 44-year-old woman with shortness of breath. She has a history of cocaine use, myocardial infarction, and frequent heart failure. No sooner than when you hang up, the patient arrives propped upright on the stretcher appearing anxious, uncomfortable, and tachypneic. You note normal neck veins and the lung sounds are clear, but markedly diminished on the right. Listening again, you think maybe this isn't just another episode of acute decompensated heart failure... 

Case Conclusions

...The 62-year-old male who complained of severe tearing inter-scapular pain was of great concern to you. While intravenous labetalol and morphine were titrated, you placed a call to CT scan to expedite his imaging. Cardiothoracic surgery and the ICU were already on board when the chest CT with contrast confirmed a descending aortic dissection.

? The 28-year-old female who was post cesarean section complaining of pleuritic chest pain was also worrisome. Anticipating anticoagulation after chest CT, you concluded the examination with a rectal examination which was negative for occult blood. After confirmation of pulmonary arterial filling defects, she was anticoagulated and admitted.

? The 32-year-old male asthmatic felt better after treatment. Lung auscultation and peak flow readings were reassuring. The order for a chest radiograph placed by your nurse was cancelled and the patient was discharged.

? The 44-year-old female with dyspnea had a history of congestive heart failure but her breath sounds were diminished on the right. You ordered intravenous analgesia and obtained a portable AP chest radiograph. Review of the frontal chest film confirmed your suspicion for pneumothorax. A repeat chest radiograph after tube thoracostomy demonstrated right lung expansion; the dyspnea improved and admission was arranged.