What are the immediate steps for a patient with sudden onset right rib pain worsening with breathing, difficulty walking, and a history of asthma and coeliac disease?

Immediate Emergency Assessment and Management

This patient requires immediate emergency department evaluation or ambulance dispatch given the constellation of sudden-onset pleuritic chest pain, dyspnea, difficulty walking, and back pain—this presentation is highly concerning for pulmonary embolism (PE) until proven otherwise, which carries significant mortality risk if untreated. 1

Critical Red Flags Requiring Immediate Action

This clinical presentation demands urgent evaluation because:

• Sudden onset right-sided pleuritic chest pain with dyspnea and difficulty walking strongly suggests PE, particularly given the radiation to the back and absence of calf swelling (which does not exclude deep vein thrombosis) 1
• Progressive worsening over 3 hours indicates an evolving, potentially life-threatening process 1
• History of asthma complicates the picture but does not explain the sudden onset or back pain component 1

Immediate Telephone Triage Decision

Advise immediate emergency department presentation via ambulance rather than self-transport given:

• Sudden onset with progressive symptoms over hours 1
• Difficulty walking suggesting hemodynamic compromise or severe pain 1
• Dyspnea in a patient with underlying asthma who may decompensate rapidly 1
• The afternoon/evening timing increases risk if this represents acute severe asthma 1

Differential Diagnosis Priority (Based on Mortality Risk)

1. Pulmonary Embolism (Highest Priority)

• Sudden onset pleuritic pain, dyspnea, back pain, and difficulty walking are classic 1
• Absence of calf swelling does NOT exclude PE 1
• Requires immediate anticoagulation if confirmed to prevent mortality 1

2. Pneumothorax

• Pleuritic chest pain and dyspnea with sudden onset 1
• Asthma patients are at risk, particularly if recent exacerbation 1
• Requires chest radiography urgently 1

3. Acute Severe Asthma Exacerbation

• History of asthma makes this consideration mandatory 1
• However, sudden onset rib pain and back pain are atypical for isolated asthma 1
• Dyspnea could represent severe bronchospasm 1

4. Acute Coronary Syndrome/Aortic Dissection

• Back pain with chest pain raises concern for dissection 1
• Less likely given age and pleuritic nature, but cannot be excluded by phone 1

Pre-Hospital Instructions While Awaiting Transport

If ambulance dispatch is arranged:

• Position patient upright to optimize breathing 1
• Administer patient's own asthma reliever (salbutamol/albuterol 2-4 puffs via MDI) if available, as dyspnea component may have bronchospasm overlay 1
• Avoid any sedatives or anxiolytics which could suppress respiratory drive 1
• Do not allow patient to walk or exert given difficulty walking and potential PE 1
• Monitor for deterioration: confusion, drowsiness, inability to speak in sentences, or loss of consciousness require immediate 999/911 call if not already made 1

Emergency Department Evaluation Protocol

Upon arrival, the patient requires:

Immediate Assessment (Within Minutes)

• Vital signs: Heart rate >110 bpm, respiratory rate >25/min, oxygen saturation, blood pressure 1
• Ability to complete sentences: If unable, this indicates severe respiratory compromise 1
• High-flow oxygen 40-60% should be initiated immediately regardless of diagnosis 1

Urgent Investigations

• Chest radiograph to exclude pneumothorax, consolidation, or pulmonary edema 1
• ECG to evaluate for cardiac ischemia or PE findings 1
• D-dimer and CT pulmonary angiography if PE suspected based on Wells score 1
• Arterial blood gas if severe respiratory distress: PaCO2 >6 kPa or PaO2 <8 kPa indicates life-threatening condition 1, 2
• Peak expiratory flow if asthma exacerbation suspected: <50% predicted indicates severe attack 1

Asthma-Specific Considerations

If acute severe asthma is contributing:

• Nebulized salbutamol 5 mg or terbutaline 10 mg via oxygen-driven nebulizer 1
• Prednisolone 30-60 mg orally or IV hydrocortisone 200 mg 1
• Add ipratropium 0.5 mg nebulized if life-threatening features present 1
• Reassess at 15-30 minutes: Persistent symptoms require admission 1

Life-Threatening Asthma Features Requiring ICU Consideration

• Silent chest, cyanosis, bradycardia, or exhaustion 1, 2
• Altered mental status or confusion 1, 2
• PaCO2 >6 kPa (normal or elevated CO2 in breathless asthmatic is paradoxical and indicates impending respiratory failure) 1, 2
• Peak flow <33% predicted 2

Critical Pitfalls to Avoid

• Do not attribute all symptoms to asthma without excluding PE, pneumothorax, or cardiac causes—the sudden onset and back pain are atypical for isolated asthma 1
• Do not delay imaging based on clinical impression alone; chest X-ray is mandatory 1
• Do not give sedatives even if patient appears anxious, as this can precipitate respiratory arrest in severe asthma or PE 1
• Do not allow patient to self-transport given difficulty walking and potential for sudden decompensation 1
• Coeliac disease history is likely incidental to this acute presentation, though it may be associated with autoimmune conditions 3; the asthma association with coeliac is weak and not relevant to acute management 4, 5

Disposition Decision

• Admit if PE confirmed for anticoagulation and monitoring 1
• Admit if pneumothorax requiring intervention 1
• Admit if acute severe asthma with persistent symptoms after initial treatment (PEF <50% predicted, inability to complete sentences, HR >110, RR >25) 1
• Discharge only if alternative benign diagnosis confirmed, symptoms fully resolved, and patient has close follow-up within 24 hours 1