Chest Pain (cont.)
The Lung
Pneumonia
An infection of the lung is called pneumonia, in which inflammation can cause
fluid buildup within a segment of the lung tissue, decreasing its ability to
transfer oxygen from air to the bloodstream.
Pneumonia presents with the typical symptoms of an infection:
There may also be:
- cough,
- shortness of breath, and
- sputum production
(coughing up mucus).
The chest pain is pleuritic, hurting when taking a deep
breath.
Physical examination may find the patient to have abnormal vital signs
consistent with an infection. The PR and RR may be elevated. A fever may be
present. Listening to the chest may reveal decreased air entry in the area of
the infection associated with crackles and occasionally wheezing because of
inflammation and narrowing of the bronchial tubes.
A chest x-ray helps make the diagnosis, though the x-ray image sometimes lags
behind the clinical findings by a day or two. Blood tests may be used to assess
the severity of illness and may include a white blood cell count (markedly
elevated or abnormally low counts may indicate more severe illness) and an
arterial blood gas level to assess lung function.
Pneumonia may be caused by a virus or bacteria. The latter is treated with
antibiotics, either by mouth or in the hospital by intravenous infusion. The
general health and past medical history of the patient may guide the decision as
to whether inpatient or outpatient therapy is most appropriate. For more, please
read the Pneumonia article.
Pulmonary embolism
A blood clot to the lung can be fatal and is one of the diagnoses that should
always be considered when a patient presents with chest pain.
While there is a classic presentation for pulmonary embolus of pleuritic
chest pain, shortness of breath, and
coughing up blood (hemoptysis), the more
common presentation is much more subtle, and the diagnosis may be easily and
unavoidably missed.
Risk factors for pulmonary embolus include:
- prolonged inactivity like a long trip in a car or airplane
- recent surgery or fracture
- birth control pills (especially associated with smoking)
- cancer
- pregnancy
Thrombophilia (thrombo=clot + philia= attraction) comprises a host of blood
clotting disorders that place patients at risk for pulmonary embolus.
The pulmonary embolus begins in veins elsewhere in the body, usually the
legs, though it can occur in the pelvis, arms, or the major veins in the
abdomen. When a thrombus or blood clot forms, it has the potential to break free
(now called an embolus) and float downstream, returning to the heart. It can
pass through the heart and into the pulmonary circulation system, eventually becoming
lodged in the branches of the pulmonary artery and cutting off blood supply to
part of the lung. This decreased blood flow doesn't allow enough blood to pick
up oxygen in the lung, and the patient can become markedly short of breath.
As mentioned above, the common complaints include:
- pleuritic chest pain from
the inflamed lung,
- bloody sputum, and
- shortness of breath.
The patient can also have
anxiety and sweat profusely. Depending upon the size of the clot, the initial
presentation may be fainting (syncope) or a passing-out spell.
Depending on the severity of the embolus and the amount of lung tissue at
risk, the patient may present critically ill (in extremis) with markedly
abnormal vital signs, or may appear rather normal. Physical examination may not
be helpful, and the diagnosis is made upon clinical suspicion based on history
and risk factors.
The diagnosis may be made directly with imaging of the lungs
or indirectly by finding a clot elsewhere in the body. The strategy used to make
a diagnosis will depend upon each individual patient's situation, but there are
some general tools available.
D-dimer is a blood test that can measure breakdown products of blood clots in
the body but cannot differentiate a pulmonary embolus from a healing scar from
surgery, or a bruise from falling. If this test is negative, then a
pulmonary embolus can usually be excluded.
Lungs can be imaged with a ventilation-perfusion scan or a CT scan to look
for a clot. Each test has its benefits and limitations, and use of these tests
is dependent upon the clinical situation. If there are technical issues so that
the lungs cannot be imaged, an ultrasound of the legs may be
performed to look for a
thrombus; the concept is that if the symptoms are present of a pulmonary embolus
and a clot is found in the leg, then the diagnosis can be inferred. Sometimes
direct angiography of the pulmonary arteries may be performed.
The treatment for pulmonary embolus is anticoagulation using either heparin
or enoxaparin (Lovenox) initially, then transitioning to warfarin (Coumadin) for long-term
treatment. The usual treatment course for anticoagulation for a pulmonary
embolus is three to six months.
The lungs and heart can stop working if there is a large enough clot load.
Aside from the basics of oxygen, intravenous fluids, and medicines to support
blood pressure, thrombolytic or clot busting therapy may be considered. In rare
and extreme cases, lytic agents may be directly injected into the area of clot.
Pulmonary embolus should always be considered a life-threatening illness.
For additional information, please read the
Pulmonary Embolism article.
The Heart
Next: Angina and heart attack »
- Beta Blockers - Learn more about Beta Blockers, a drug that treats angina and other heart rhythm disorders, migraines, high blood pressure, panic attacks, and tremors. Generic and brand names are included in the article.
- CT Scan (Computerized Axial Tomography) - CT Scan (Computerized Axial Tomography, CAT scan) is a procedure that assists in diagnosing tumors, fractures, bony structures, and infections in the organs and tissues of the body.
- Pneumonia - Learn pneumonia symptoms, causes, treatment, signs, diagnosis and types: viral and bacterial (Pneumocystis carinii, Klebsiella, Mycoplasma, Chlamydia pneumoniae).
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