Prototype case flow — v3

34F, chest pain and breathlessness

GP — same-day appointment
History
Examination
Assessment
Investigations
Diagnosis
Presents with

Chest pain and breathlessness.

History so far
Examination so far
Take a history

Every category is here for every case, whether or not it turns out relevant. Open whatever you'd genuinely ask.

Ask anything else

For anything not covered above. Answers stay consistent with the case — expect a plain "nothing of note" if it's outside what's documented.

Observations
Examine

Every system is available for every case — pick the ones this presentation actually calls for.

Your assessment

Not marked — just worth committing to something before you see what's next.

Available today

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Your pattern

Pulmonary embolism

most likely from an evolving right calf DVT

Pertinent history

  • Long-haul flight ten days ago (Social History → Travel)
  • Combined oral contraceptive pill started six weeks ago (Medications)
  • Calf ache not volunteered — only surfaced when asked directly (Associated Symptoms)
  • Maternal history of DVT (Family History)

Pertinent examination

  • Right calf swelling and tenderness, asymmetric to the left (Cardiovascular)
  • Heart rate persistently 95–100 through the consultation — relatively tachycardic for someone otherwise well-looking
  • Rib tenderness on palpation (Respiratory) is a distractor: reproducible chest wall tenderness does not exclude PE

Investigations

  • ECG: sinus tachycardia, rate 98, no acute ST changes (rhythm strip) — a normal ECG doesn't rule out PE
  • No same-day D-dimer or CTPA were available in this GP setting — the correct action on a PE-likely Wells score was urgent same-day emergency assessment rather than waiting on a test this setting couldn't provide in time anyway

Pathophysiology & management

Oestrogen-driven hypercoagulability plus venous stasis from prolonged immobility on the flight promotes clot formation in the deep veins of the calf. A fragment embolises to the pulmonary circulation, causing local V/Q mismatch — the mechanism behind the pleuritic pain and breathlessness. Two-level Wells scoring here comes out as PE-likely, which routes straight to urgent same-day imaging rather than community D-dimer. COCP would be stopped and anticoagulation started once confirmed.

Why not the other differentials

Musculoskeletal chest pain
Doesn't explain the tachycardia, breathlessness, or calf findings. Reproducible tenderness alone isn't specific enough to close the case.
Pneumonia
No fever, no cough, clear chest, no focal signs on auscultation.
Anxiety / panic attack
Could explain tachycardia and breathlessness in isolation, but doesn't account for the calf findings or the risk factor combination — never the safe default once a PE differential is live.