From the Guidelines
A D-dimer test is not typically needed in this case, as the presentation of right-sided chest pain worsening with movement in an obese 42-year-old male is more suggestive of musculoskeletal pain rather than a pulmonary embolism (PE). The pain characteristics, such as worsening with movement, point away from PE as the likely diagnosis 1. According to the American College of Physicians, clinicians should not obtain d-dimer measurements or imaging studies in patients with a low pretest probability of PE and who meet all Pulmonary Embolism Rule-Out Criteria 1.
Key Considerations
- The patient's symptoms are more consistent with musculoskeletal pain, which can be managed with over-the-counter pain relievers like ibuprofen (400-600 mg every 6-8 hours) or acetaminophen (500-1000 mg every 6 hours) as needed.
- A thorough physical examination, including chest wall palpation and assessment of ROM, should be performed to rule out other potential causes of chest pain.
- If there are additional risk factors for PE (e.g., recent surgery, prolonged immobilization, or family history of clotting disorders) or if the pain is accompanied by shortness of breath, rapid heart rate, or other concerning symptoms, then further evaluation for PE, including D-dimer testing, may be warranted 1.
- Clinicians should use validated clinical prediction rules to estimate pretest probability in patients in whom acute PE is being considered, and reserve imaging studies for patients with a high pretest probability of PE or those who do not meet the Pulmonary Embolism Rule-Out Criteria 1.
Management
- Focus on symptom management and monitoring for any changes in the patient's condition.
- Consider ordering a chest X-ray to rule out other potential causes of chest pain, such as pneumonia or rib fracture.
- Advise the patient to follow up if symptoms worsen or do not improve within a few days.
From the Research
Patient Profile
- Age: 42 years old
- Obesity: Yes
- Symptom: Right-sided chest pain worsening with movement
Relevant Studies
- The patient's symptoms could be indicative of pulmonary embolism (PE) 2, 3
- A D-dimer test can be used to rule out PE, especially in patients with a low pre-test probability 2
- However, the test's sensitivity and specificity may vary, with high levels of false-positive results, especially among older populations 2
- Age-related adjustment of D-dimer levels may be used to increase its diagnostic power 4
Diagnostic Considerations
- The patient's right-sided chest pain worsening with movement could be a symptom of PE, but other conditions such as acute coronary syndrome, acute aortic syndrome, or myopericarditis should also be considered 3, 4, 5
- A thorough medical history, physical examination, and additional diagnostic tests such as electrocardiogram, echocardiogram, and cardiac MRI may be necessary to determine the underlying cause of the patient's symptoms 5