What do you see on the CXR that makes you hesitate to initiate heparin?
A 63-year-old woman with a history of GERD is sent to the ED by her primary care physician for new onset of atrial fibrillation. She has also had 9 days of intermittent right-sided subcostal pain and had gallstones diagnosed by ultrasound 4 days ago, performed at another ED. The patient states that the pain lasts for hours, is sharp, and radiates to the right scapula and mid-chest. It seems to be worse after meals or with activity. She also vomits when the pain gets more severe. She denies palpitations, trouble breathing, syncope, or near syncope.
She is afebrile with an irregular pulse of ~120 beats/min, a blood pressure of 162/98 mm Hg, a normal pulse oximetry reading and normal respiratory rate. She appears in no acute distress and rates her current pain as 4/10. Head and neck exam findings are normal without icterus. She has clear lungs and an irregular heart beat with a soft murmur. Her abdomen is nontender without mass. Extremities are warm with good pulses and without edema.
Laboratory data show normal liver function, troponin, and chemistry but a WBC count of 17 and a very low TSH. An ECG shows atrial fibrillation at a rate of 124 beats/min with no ischemic changes. Her portable chest x-ray is shown in Figure 1 and is read by the radiologist as normal.
She is started on diltiazem for rate control and is seen by the hospitalist for admission orders, a general surgeon for her gallbladder, an endocrinologist for her hyperthyroidism, and a cardiologist for the atrial fibrillation. They all recommend starting heparin and admitting the patient to telemetry and agree they will consider cholecystectomy once her heart and endocrine conditions are stabilized.
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