Practice Rational Imaging

Investigating severe interscapular pain

BMJ 2008; 337 doi: https://doi.org/10.1136/bmj.a688 (Published 21 July 2008) Cite this as: BMJ 2008;337:a688
  1. Ali A Haydar, radiologist1,
  2. Gareth Morgan-Hughes, cardiologist2,
  3. Carl Roobottom, radiologist1
  1. 1Peninsula Radiology Academy, Plymouth PL6 5WR
  2. 2Cardiology Department, Derriford Hospital, Plymouth
  1. Correspondence to: A Haydar drahaydar{at}hotmail.com
  • Accepted 5 April 2008

This article explores the radiological investigations for identifying the cause of severe interscapular pain, focusing on how to exclude acute myocardial infarction, aortic dissection, and pulmonary embolism

A 52 year old woman presented with a sudden onset (two hour history) of severe interscapular burning pain associated with shortness of breath. Her medical history was unremarkable except for a strong family history of coronary heart disease.

Examination was normal apart from a blood pressure of 150/80 mm Hg and heart rate of 110 beats/min. The respiratory rate was 14 breaths/min, and the patient was afebrile with otherwise normal cardiorespiratory examination. Chest radiography showed borderline widened mediastinum and upper lobe venous congestion. Electrocardiography showed non-specific changes in the T waves. Blood gas analysis showed the patient to be hypoxic (PaO2 = 8 kPa (normal 8-14 kPa)), with no evidence of carbon dioxide retention. Her full blood count and biochemical profile were normal except for mildly raised C reactive protein and positive D-dimers. Baseline level of troponin I was <0.01 ng/ml.

Chest pain was partially relieved by glyceril trinitrate spray; subsequently the patient was given a morphine injection to ease her pain.

What are the next investigations?

The three important diagnoses that need to be excluded (the “triple rule out”) are:

  • Acute myocardial infarction

  • Acute aortic syndrome (aortic dissection or intramural haematoma)

  • Pulmonary embolism.

A clear diagnosis in this patient’s case must be established before any treatment is started …

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