What is the appropriate assessment and management for an elderly woman with a history of smoking (1 pack per day for 15 years) and oral contraceptives use, presenting to the emergency department with chest pain and mild shortness of breath that worsens with deep breathing and exertion?

Assessment and Management of Elderly Woman with Pleuritic Chest Pain, Dyspnea, and High VTE Risk

This patient requires immediate evaluation for pulmonary embolism (PE) as the primary concern, given the combination of pleuritic chest pain, exertional dyspnea, tachypnea, smoking history, and oral contraceptive use—all major risk factors for venous thromboembolism. 1

Immediate Triage and Initial Actions

Obtain stat 12-lead ECG within 10 minutes of arrival and place on continuous cardiac monitoring with defibrillation capability, as chest pain with dyspnea requires exclusion of both acute coronary syndrome (ACS) and PE. 1

The triage assessment should document:

• Central/substernal chest pain characteristics: pressure, tightness, radiation patterns 1
• Pleuritic features: pain worsening with deep breathing strongly suggests PE, pericarditis, or pleuritis rather than typical ACS 1
• Exertional component: shortness of breath with stair climbing indicates significant cardiopulmonary compromise 1
• Associated symptoms: diaphoresis, nausea, lightheadedness (ACS indicators) 1

Primary Differential Diagnoses

1. Pulmonary Embolism (Highest Priority)

Risk factors present:

• Oral contraceptive use (increases VTE risk 3-6 fold) 2
• Smoking history (15 pack-years) 2
• Pleuritic chest pain (classic PE presentation) 1
• Exertional dyspnea and tachypnea 1

Immediate investigations:

• D-dimer if Wells score suggests low-moderate probability 1
• CT pulmonary angiography (CTPA) if high clinical suspicion or positive D-dimer 1
• Arterial blood gas to assess hypoxemia and A-a gradient 1
• Lower extremity venous duplex ultrasound to identify DVT source 2

Physical examination findings to assess:

• Tachycardia and tachypnea (present in >90% of PE patients) 1
• Hypoxemia on pulse oximetry 1
• Unilateral leg swelling or calf tenderness 1

2. Acute Coronary Syndrome (Must Exclude)

Despite pleuritic features being atypical for ACS, elderly patients and women frequently present with atypical symptoms. 1

Immediate investigations:

• Serial cardiac troponins at presentation and 6 hours later (single measurement insufficient to exclude NSTEMI) 1
• 12-lead ECG looking for ST-segment depression, T-wave inversions, or new Q waves 1
• Continuous cardiac monitoring for arrhythmias 1

Interpretation:

• Elevated troponin (>99th percentile) with appropriate clinical context = NSTEMI 1
• Normal troponins at 0 and 6 hours with non-ischemic ECG effectively excludes ACS 1
• ECG may show sinus tachycardia, right heart strain pattern (S1Q3T3), or right bundle branch block if PE present 1

3. Pneumothorax

Pleuritic pain with dyspnea in a smoker raises concern for spontaneous pneumothorax. 3

Immediate investigations:

• Chest X-ray (PA and lateral) to identify pneumothorax, infiltrates, or effusion 1
• Look for absent lung markings and visceral pleural line 3

4. Acute Pericarditis

Pleuritic chest pain relieved by sitting forward suggests pericarditis. 1

Assessment:

• ECG findings: diffuse ST elevation with PR depression 1
• Positional relief: pain improves leaning forward 1
• Pericardial friction rub on auscultation 1

Complete Initial Laboratory Workup

Draw immediately upon arrival:

• Cardiac troponin I or T (repeat at 6 hours) 1
• D-dimer (if PE probability low-moderate by Wells criteria) 1
• Complete blood count (assess for anemia, thrombocytosis) 1
• Basic metabolic panel (electrolytes, renal function) 1
• Arterial blood gas (if hypoxemic or high PE suspicion) 1
• Brain natriuretic peptide (BNP) if heart failure suspected 1

Imaging Strategy

Sequence based on clinical probability:

1. Chest X-ray (first-line for all patients): identifies pneumothorax, infiltrates, cardiomegaly, pleural effusion 1

2. CT pulmonary angiography if:

   • High clinical suspicion for PE 1
   • Positive D-dimer with intermediate probability 1
   • Unexplained hypoxemia or tachypnea 1

3. Echocardiography if:

   • Elevated troponins to assess wall motion abnormalities 1
   • Suspected right heart strain from massive PE 1
   • Hemodynamic instability 1

Critical Pitfalls to Avoid

Do not dismiss pleuritic chest pain as "non-cardiac" without excluding PE—this is the most dangerous error in this presentation, as oral contraceptives and smoking create substantial VTE risk. 2, 1

Do not rely on a single troponin measurement—serial troponins at 0 and 6 hours are required to exclude NSTEMI, as biomarkers may not be elevated immediately after symptom onset. 1

Do not assume elderly women present with "typical" ACS symptoms—women and elderly patients frequently have atypical presentations including isolated dyspnea, nausea, or fatigue without classic substernal chest pressure. 1

Do not overlook medication history—oral contraceptive use in a woman described as "elderly" is unusual and warrants verification, as combined hormonal contraceptives are generally contraindicated in women >35 years who smoke due to stroke and VTE risk. 2

Do not delay anticoagulation if PE is highly suspected—if CTPA will be delayed and clinical probability is high, consider empiric anticoagulation while awaiting imaging. 1

Risk Stratification for Disposition

High-risk features requiring admission:

• Hypotension or hemodynamic instability 1
• Hypoxemia requiring supplemental oxygen 1
• Elevated troponins 1
• ECG changes consistent with ischemia or right heart strain 1
• Confirmed PE or ACS 1

Intermediate-risk features:

• Tachycardia >100 bpm 1
• Tachypnea >20 breaths/min 1
• Positive D-dimer awaiting CTPA 1

This patient's tachypnea alone warrants admission for observation and completion of diagnostic workup. 1