Young Female Patient with Chest Pain - Should We Use PAPPA?

young-patient-chest-pain-cxr

12 y/o Patient with Chest Pain – Should We Use PAPPA?

When a young child presents with chest pain, sometimes it can be easy to take their age for granted when coming to a diagnosis. However, there are some high-risk signs that you can’t afford to miss or the outcome could be deadly.  You need to be proactive to avoid getting burned! One of the worst things that can happen is when you come in to work and hear, “Hey, remember that patient you saw the other day…?”

That conversation rarely ends well.

However, we can avoid missing the high-risk signs of chest pain by applying the famous PAPPA mnemonic. Any time a patient presents with symptoms such as chest pain, pressure, shortness of breath, indigestion, or cough, you have to ask, “Who’s Your PAPPA?”

The Case

You’ll never come across a patient too young to apply the PAPPA mnemonic. This particular patient presented for a facial rash, buttock pain and some mild flank chest discomfort. She had recently traveled from the United States to the Philippines 1 month prior. She denied dysuria. No cough, no dyspnea. She expressed discomfort and said, “But my side kind of hurts” while she was ambulating around the room.

Review this Chest X-Ray of the 12 y.o. female patient.

Vital Signs read: HR 146, bp 88/50, RR 18, o2 sat 98% RA. Non toxic, well appearing. Her mom had taken her to the clinic the day before for the “facial rash” and was given labs they hadn’t done yet (an ESR, ANA).

Her heart rate was pretty elevated for her age and she was at rest. No hx of vomiting or diarrhea. CXR was read as normal by the radiologist. She had some labs. CBC was mildly elevated and her temp went up to 100.0. She was given Tylenol and an oral fluid challenge. No change in HR.

The Diagnosis

The CXR was reviewed and there was a new triangular density noted on the right noted by the ER provider who thought maybe it was a pneumonia and gave her Rocephin. The PAPPA mnemonic was used!

P – Pericardial tamponade: no water bottle sign seen on XR.

A – ACS: not within age range.

P – PE

P – Pneumothorax: not seen on XR.

A – AAA: doubtful.

Based on the unrelenting tachycardia and abnormal chest xray, she was sent for a D-Dimer that was over 4000. CT scan showed a massive PE, she was transferred to a higher level of care and enroute had a run of VT.

She ultimately did well, but what caused the PE in this 12 year old female?


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Jennifer Carlquist

Jennifer works full time in cardiology and part time in an emergency room and urgent care clinic. She has lectured at conferences across the country on EKGs and cardiology related topics and her work has even been published in the Journal of the American Academy of Physician Assistants (JAAPA). Jennifer is an alumnus of the University of California, Davis PA Program in Sacramento, CA. “My favorite part about CME4Life is that I have been with the company for eight years now and John always makes the conferences just as fun for the attendees as it is for the speakers.”
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