Intended for healthcare professionals

Endgames Case Review

Severe chest pain in an asthmatic patient

BMJ 2017; 358 doi: (Published 13 July 2017) Cite this as: BMJ 2017;358:j2972
  1. Michael Dromey, ST1 emergency medicine,
  2. Chukwuemeka Nwaneri, emergency, medicine registrar,
  3. David Wilson, consultant emergency medicine
  1. Countess of Chester Hospital, Chester, UK
  1. Correspondence to M Dromey mike{at}

A 20 year old woman with a history of asthma presented to the emergency department complaining of shortness of breath and sharp pains in her chest and neck. The pain was worse on deep inspiration. She had a cough which produced small amounts of whitish sputum. The patient had had several previous exacerbations of asthma, and recently had not been using her inhalers regularly. On examination, her airway was patent and she had a generalised moderate wheeze in her chest, but no other obvious clinical signs. She could speak in full sentences and had normal oxygen saturations and temperature. She was mildly tachycardic and appeared slightly anxious. Her blood tests showed a mild neutrophilia and elevated C reactive protein.

She was given salbutamol and ipratropium nebulisers. These improved her wheezing, but she still complained of a severe central chest pain. In light of the unresolved chest pain and raised inflammatory markers, a chest radiograph was performed (fig 1)

Fig 1

Chest radiograph


  • 1. What does this radiograph show?

  • 2. Which common investigation should be avoided in patients with this diagnosis?

  • 3. What are the next steps in management of patients with this diagnosis?


1. What does this radiograph show?

Short answer

The radiograph …

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