CASE 40: PAIN IN THE CHEST AND SHORTNESS OF BREATH
History
A 16-year-old African-Caribbean boy presents to the emergency department complaining
of severe chest pain and shortness of breath. He has had a sore throat for a few days and
started developing pain in his back and arms which has increased in severity. Six hours
prior to admission he suddenly developed right-sided chest pain which is worse on inspir-
ation and associated with marked breathlessness. He has had previous episodes of pains
affecting his fingers and back, for which he has taken codeine and ibuprofen. He was born
in London and lives with his parents and younger sister. He is attending school and has
had no problems there. There is no family history of note.
Examination
He is unwell, febrile 37.8°C and cyanosed. His conjunctivae are pale. Pulse rate is 112/min,
regular and blood pressure 136/85 mmHg. His jugular venous pressure is not raised and
heart sounds are normal. His respiratory rate is 28/min and there is a right pleural rub
audible. Abdominal and neurological examination is normal. There are no rashes on the
skin and no joint abnormalities.
NormalHaemoglobin 7.6 g/dL 13.3–17.7 g/dL
Mean corpuscular volume (MCV) 86 fL 80–99 fL
White cell count 16.2% 109 /L 3.9–10.6% 109 /L
Platelets 162 % 109 /L 150–440% 109 /L
Sodium 139 mmol/L 135–145 mmol/L
Potassium 4.4 mmol/L 3.5–5.0 mmol/L
Urea 6.2 mmol/L 2.5–6.7 mmol/L
Creatinine 94 &mol/L 70–120&mol/L
Bicarbonate 24 mmol/L 24–30 mmol/L
Arterial blood gases on air:
pH 7.33 7.38–7.44
pCO 2 2.6 kPa 4.7–6.0 kPa
pO 2 7.2 kPa 12.0–14.5 kPaElectrocardiogram (ECG): sinus tachycardia
Chest X-ray: normalINVESTIGATIONS
Questions
- What is the likely diagnosis?
- How would you investigate and manage this patient?