How should a 46-year-old female presenting with acute neck and upper back pain radiating to the anterior chest, new chest tightness, paresthesias, cough with phlegm, dry throat, and skin discoloration be evaluated and managed?

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Immediate Evaluation and Management

This patient requires urgent evaluation for life-threatening causes of chest pain, specifically aortic dissection, pulmonary embolism, and acute coronary syndrome, with immediate transthoracic echocardiography (TTE) and computed tomography angiography (CTA) of the chest based on clinical findings. 1

Critical Red Flags Present

This 46-year-old woman presents with multiple concerning features that mandate aggressive workup:

  • Acute onset severe pain (8/10) radiating from neck/back to anterior chest
  • New paresthesias and swelling sensation suggesting neurovascular compromise
  • Pain worsening with breathing and neck movement
  • New skin discoloration (potentially petechiae or livedo reticularis)
  • Respiratory symptoms with productive cough

While the EKG shows no ischemic changes, this does not rule out life-threatening pathology 1.

Algorithmic Approach to Workup

Step 1: Immediate Bedside Assessment

Perform focused cardiovascular examination looking specifically for:

  • Pulse differentials between extremities (30% sensitive for aortic dissection) 1
  • Blood pressure in both arms
  • Cardiac auscultation for new murmurs (aortic regurgitation occurs in 40-75% of Type A dissections) 1
  • Unilateral absence of breath sounds (pneumothorax)
  • Dermatomal skin changes (herpes zoster) vs. diffuse discoloration

Step 2: Obtain Troponin Immediately

Cardiac troponin should be measured as soon as possible even with normal EKG, as the examination may be completely normal in uncomplicated acute coronary syndrome 1.

Step 3: Risk-Stratify for Aortic Dissection

The combination of:

  • Severe pain with abrupt onset
  • Back and chest pain radiation pattern
  • Pain worsening with breathing
  • New neurologic symptoms (paresthesias)

Creates high clinical concern for aortic dissection. 1

If aortic dissection is suspected, CTA of the chest, abdomen, and pelvis is the Class I recommendation for diagnosis and treatment planning 1. This is both highly sensitive and specific and should not be delayed.

Step 4: Evaluate for Pulmonary Embolism

The presentation includes:

  • Chest pain worsening with breathing (pleuritic quality)
  • Cough with phlegm
  • Potential for tachycardia

In stable patients with high clinical suspicion for PE, CTA using a PE protocol is recommended (Class I) 1. The pretest probability should guide whether this is performed simultaneously with or instead of aortic imaging.

Step 5: Transthoracic Echocardiography

TTE is recommended (Class I) when other potentially life-threatening nonischemic cardiac conditions are suspected 1. This should be performed promptly to evaluate for:

  • Pericardial effusion/tamponade
  • Aortic dissection flap visualization
  • Acute valvular pathology
  • Right ventricular dysfunction (PE)

Practical Clinical Decision Point

Given the constellation of findings, the most likely serious diagnoses are:

  1. Aortic dissection - radiation pattern, severity, neurologic symptoms
  2. Pulmonary embolism - pleuritic features, respiratory symptoms
  3. Acute coronary syndrome - though less likely with normal EKG

The imaging strategy should be:

  • If pulse differential or blood pressure differential exists → immediate CTA chest/abdomen/pelvis for aortic dissection 1
  • If no pulse differential but high PE suspicion → CTA chest with PE protocol 1
  • TTE should be performed urgently regardless to evaluate cardiac structure and function 1

Critical Pitfalls to Avoid

  • Do not dismiss chest pain based on normal EKG alone - aortic dissection and PE frequently have normal or nonspecific EKG findings 1
  • Do not attribute symptoms to musculoskeletal causes without ruling out life-threatening pathology first, despite pain worsening with movement 1
  • Do not delay imaging for serial troponins if aortic dissection is suspected - this is a surgical emergency 1
  • The skin discoloration requires explanation - consider embolic phenomena from aortic dissection, vasculitis, or other systemic process

Disposition

This patient requires emergency department evaluation and should not be managed in an outpatient setting 1. If initially seen in office, she should be transported urgently to the ED, ideally by EMS 1.

The respiratory symptoms and skin findings may represent:

  • Embolic phenomena from cardiac/aortic source
  • Concurrent infectious process (though no fever reported)
  • Vasculitic process

These require inpatient workup after life-threatening causes are excluded.

References

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