CASE 50: CHEST PAIN AND SHORTNESS OF BREATH
History
A 29-year-old woman complained of a sudden onset of right-sided chest pain with short-
ness of breath. It woke her from sleep at 3.00 am. The pain was made worse by a deep
breath and by coughing. The breathlessness persisted over the 4 h from its onset to her
arrival in the emergency department. She has a slight non-productive cough. There is no
relevant previous medical history except asthma controlled on salbutamol and beclometa-
sone. There is no family history of note. She works as a driving instructor and had returned
from a 3-week holiday in Australia 3 weeks previously. She had no illnesses while she was
away. She has taken an oral contraceptive for the last 4 years.
Examination
She has a temperature of 37.4°C, her respiratory rate is 24/min, the jugular venous pressure
is raised 3 cm, the blood pressure is 110/64 mmHg and the pulse rate 128/min. Peak flow rate
is 410 L/min. In the respiratory system, expansion is reduced because of pain. Percussion and
tactile vocal fremitus are normal and equal. A pleural rub can be heard over the right lower
zone posteriorly. There are no other added sounds. Otherwise the examination is normal.
- An electrocardiogram (ECG) is shown in Fig. 50.1.
- Fig. 50.2 shows her chest X-ray.
INVESTIGATIONS
Figure 50.1Electrocardiogram.