An 18-year-old, otherwise healthy, young male reporting a 1-week history of muscular pain, a sore throat and a non-productive cough presented to the emergency room with acute chest pain and pain of the left shoulder. He also experienced some dizziness, without collapse, nausea or vomiting. He reported fever, but this was not objectively confirmed. There was no history of haemoptysis, wheezing, allergic reactions or weight loss. There was no significant family history of similar or other illnesses.
Task 1
What can cause acute chest pain in an otherwise healthy young adult?
Answer 1
In this case you would suspect an infectious cause like a pneumonia or viral pleurisy/pericarditis. A pulmonary embolus could also give some fever and a cough.
In the case of a young male you should always consider the possibility of a pneumothorax. Less obvious are cardiac ischaemia, myocarditis or pericarditis, myalgia or orthopaedic causes (table 1).
Aortic dissection is also a possible differential diagnosis (particularly in patients with Marfan’s syndrome.
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On examination he had normal vital signs with a systolic/diastolic blood pressure of 135/65 mmHg, a heart rate of 80 beats·min−1, a regular respiratory rate of 15 breaths·min−1, a temperature of 37°C, normal cardiac examination, normal breath sounds, normal chest percussion and no signs of a deep vein thrombosis (DVT). Ear, nose and throat examination revealed a right-sided submandibular enlarged lymph node, but no enlarged or exudative tonsils. His shoulder examination showed some tenderness in the region of the left deltoid muscle, but no signs of fracture or dislocation.
The laboratory data showed elevated white blood counts with a marked leftward shift, a high C-reactive protein (CRP) and elevated D-dimers (table 2). White blood cell counts were 15.2×109·L−1, with 77% segmented granulocytes, 13% band cells (or stab cells); d-dimers were 1011 ng·mL …
