Chest Pain OSCE - Pulmonary Embolism

Case Overview

• Age/Sex: 42-year-old female
• Occupation: Office manager
• Setting: Emergency department / urgent assessment clinic
• Chief complaint: "Chest pain"

Patient Script

Who I Am

I’m 42, I work in an office, and I had surgery two weeks ago to remove my gallbladder.

What Brings Me In

I’ve had this uncomfortable chest pain since last night and I’m worried it might be something serious.

My Story

I started getting a sharp, uncomfortable pain in my right-sided chest yesterday evening that wakes me when I breathe deeply. It’s not a heavy pressure feeling like someone sitting on my chest — it’s more like a stabbing pain when I take a deep breath and if I cough. It’s been there all night and is still there now, worse when I move or take deep breaths. I also felt a bit short of breath when I walked up a flight of stairs today, which I didn’t expect. I had my laparoscopic gallbladder removal two weeks ago and spent two nights in hospital; they gave me some injections to prevent clots while I was in. I’ve been up and about at home since going home but didn’t do much the first week.

I’ve also had some heartburn off and on for years and sometimes get anxious when I feel my heart racing — that’s happened before. I had a mild cough last week like a cold but it went away. The pain isn’t really spreading to my jaw or left arm. I’m not pregnant.

My Medical Background

• Past medical history: Obesity (I’m heavier than I used to be), occasional heartburn, anxiety with prior panic attacks years ago
• Recent surgery: Laparoscopic cholecystectomy 14 days ago, inpatient for 2 nights; received standard VTE prophylaxis while inpatient
• Medications: paracetamol PRN, omeprazole for reflux; no regular anticoagulants
• Allergies: none known
• Social: lives with partner, works full time, ex-smoker, quit 5 years ago (10 pack-years), drinks socially, not currently using hormonal contraception
• Family history: father had a heart attack in his 60s

What I Think & Worry About

• I’m worried it might be my heart — I don’t want a heart attack.
• I worry it could be a blood clot because of the surgery I had recently.
• I also think it might just be my reflux or my anxiety acting up.

If You Ask Me About Other Symptoms...

• Breathlessness: "A bit short of breath if I hurry or walk up stairs, but I can talk in full sentences."
• Cough: "I had a mild cough last week but it’s mostly gone."
• Leg symptoms: "My left calf was a bit sore the day before yesterday, but it’s not swollen now and it’s much better." (red herring — mild calf discomfort)
• Fever/sweats: "No fevers, no night sweats."
• Palpitations: "I noticed my heart racing once last night for a few minutes, it settled down."
• Chest wall tenderness: "If I press over the lower ribs on the right it hurts a bit — I thought it might be from reaching for something yesterday." (red herring — reproducible tenderness)
• Vomiting/diarrhea: "No."

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Clinical Summary

Examination

• General: alert, mildly anxious
• Vital signs: HR 110 bpm (sinus on monitor), BP 128/82 mmHg, RR 22/min, SpO2 94% on room air, Temp 36.7°C
• Cardiorespiratory: heart sounds normal, no murmurs; chest auscultation clear bilaterally, no focal crackles
• Chest wall: mild tenderness to palpation over right lower costal margin (reproducible)
• Peripheral: no obvious unilateral calf swelling; mild tenderness in left calf on deep palpation without erythema or significant asymmetry
• Abdominal: soft, non-tender

Investigations

• ECG: sinus tachycardia 110 bpm, no ST-elevation; possible new T-wave inversion in V1–V3 (suggestive of right heart strain/strain pattern)
• CXR (AP): clear lung fields, no consolidation or pneumothorax
• Pulse oximetry/ABG: SpO2 94% on air; ABG shows mild hypoxemia PaO2 ~ 10.5 kPa (79 mmHg)
• D-dimer: 2,000 ng/mL (elevated; reference <500 ng/mL)
• Troponin I: 0.02 ng/mL (within reference range or minimally raised depending on lab; not consistent with STEMI)
• Lower limb venous duplex ultrasound: no definitive DVT in calves (may be negative)
• CT pulmonary angiography (CTPA): filling defect in segmental branches of the right lower lobe pulmonary artery (positive for pulmonary embolism)

Diagnosis

• Primary diagnosis: Acute pulmonary embolism (segmental right lower lobe PE)

  • Evidence: recent surgery within 4 weeks (risk factor), pleuritic chest pain, mild exertional dyspnea, tachycardia, elevated D-dimer, ECG with signs of possible right heart strain, and CTPA demonstrating filling defect in right lower lobe pulmonary artery.

• Differential diagnoses and reasoning:

  • Acute coronary syndrome — less likely due to pleuritic nature of pain, non-localising ECG changes, and normal/near-normal troponin.
  • Musculoskeletal chest wall pain — reproducible tenderness supports this, but does not explain tachycardia, hypoxemia, or positive D-dimer/CTPA.
  • Pneumonia/pleuritis — CXR clear, afebrile, no consolidation; unlikely.
  • Anxiety/panic attack — history present (red herring) but clinical findings (SpO2 94%, tachycardia, positive D-dimer, CTPA) point to PE.

Management

• Immediate:

  • Start therapeutic anticoagulation promptly (e.g., low molecular weight heparin weight-adjusted or initiate DOAC per local protocol such as apixaban or rivaroxaban if no contraindications) now that PE confirmed.
  • Oxygen to maintain SpO2 ≥94% if required; patient currently 94% on room air — monitor.
  • Analgesia for pain as required (paracetamol; avoid NSAIDs if concern about bleeding and timing of anticoagulation).

• Further in-hospital steps:

  • Baseline bloods including FBC, U&E, LFTs, coagulation screen, pregnancy test if applicable.
  • Risk stratification for right ventricular dysfunction (troponin, BNP, bedside echo if available) to assess for massive/submassive PE and need for escalation.
  • Monitor vital signs and oxygenation; consider cardiology/respiratory consult if RV strain or instability.
  • Once stabilized and no contraindications, plan for transition to oral anticoagulation (DOAC or warfarin) and arrange duration of therapy (e.g., at least 3 months) with assessment of ongoing risk factors.
  • Advise mobility, consider thrombophilia testing only if unprovoked or other indications.
  • Educate patient on bleeding risk, signs of recurrence, and follow-up arrangements.

Key Learning Points

• Consider pulmonary embolism in patients with new pleuritic chest pain and tachycardia after recent surgery even if chest x-ray is normal and respiratory exam is unremarkable.

• Be cautious of red herrings: reproducible chest wall tenderness, prior anxiety, and known reflux do not exclude PE; combine risk factors (recent surgery, immobilization) with vital signs and D-dimer/CTPA to guide diagnosis.

• Manage confirmed PE promptly with therapeutic anticoagulation and risk stratify for right ventricular dysfunction to determine need for higher-level interventions.