Endgames Picture Quiz

Chest pain and neck discomfort in a young man

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g1661 (Published 25 February 2014) Cite this as: BMJ 2014;348:g1661
  1. Dermot Linden, core medical trainee1,
  2. David Courtney, general practitioner trainee2,
  3. Muralis Shyamsundar, specialty registrar 3,
  4. Richard Hewitt, consultant3
  1. 1Department of Intensive Care, Ulster Hospital, Belfast BT16 1RH, UK
  2. 2Department of Medicine, Ulster Hospital, Belfast, UK
  3. 3Department of Respiratory Medicine, Ulster Hospital, Belfast, UK
  1. Correspondence to: D Linden dermotlinden{at}gmail.com

A 21 year old man presented to his general practitioner with intermittent left sided pain in the anterior chest wall associated with neck discomfort. The pain was reported as “stabbing” in nature and had arisen suddenly while watching television. He had no history of trauma before the onset of symptoms, and the pain was not exacerbated by inspiration or effort. His medical history and physical examination were unremarkable. His GP referred him for outpatient cardiology assessment and prescribed simple analgesia.

Several days later he attended the local emergency department with worsening chest pain and dyspnoea. On examination, chest expansion was equal and breath sounds were normal, although there was crepitus on auscultation of the precordium. Palpation of the neck and supraclavicular fossae detected subcutaneous emphysema. His respiratory rate was 25 breaths/min and his oxygen saturations were 100%. A chest radiograph (fig 1) was abnormal and he was admitted for computed tomography of the chest. No abnormalities were seen on a water soluble oral contrast swallow. His full blood count and inflammatory markers were within normal limits.

Fig 1 The patient’s chest radiograph on admission

Questions

  • 1 What abnormality is shown on the chest radiograph?

  • 2 What is the most likely diagnosis?

  • 3 What are the differential diagnoses?

  • 4 What does crepitus on auscultation of the precordium indicate? …

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