Case 13: Chest pain

Opening scenario

Anthony Price, a 35-year-old male; , comes to the emergency department because of chest pain.

Vital signs

• Temperature: 98.6°F (37°C)
• Blood pressure: 135/80 mm Hg
• Heart rate: 105/min
• Respirations: 24/min
• BMI: 19.4 kg/m²

Examinee tasks

• Take a focused history.
• Perform a relevant physical examination (do not perform corneal reflex, breast, pelvic/genitourinary, or rectal examinations).
• Explain the preliminary differential diagnoses and initial workup plan to the patient.
• Write the patient notes after leaving the room.

Patient instructions

• You are not aware of the meanings of medical terms (e.g., x-ray), and ask for clarification if the examinee uses them.
• Either use makeup or a marker to simulate some small scratches on your palms. Alternatively, tell the examinee that there are some small scratches on your palms.
• When the examinee asks you to take deep breaths so he/she can listen to your chest, tell him/her that doing so causes pain on your left side of your chest.
• When the examinee touches and/or presses the left side of your chest, tell her/him that it is very painful.
• When the examinee listens to the left side of your chest, hold your breath and raise your shoulders as if you were breathing. When the examinee listens to the other side of your chest, breathe normally.
• When the examinee asks you to say a phrase such as “toy boat,” say the phrase softly while the examinee listens to your left lung or feels your left lung. When the examinee listens to the other side of your chest or feels the other side of your chest, say the phrase at normal volume.
• Use the checklists below for history, physical examination, and communication and interpersonal skills.

Challenge: Once the examinee is done taking the history, show him/her the following x-ray and say “The staff in the emergency department already sent me to get this picture taken. Can you explain it to me?”

Hovering over or clicking on the speech bubbles in the lists below will reveal extra information about the adjacent term. However, clicking on links will cause you to navigate away from the current case, at which point your progress (i.e., your check marks) will be lost. If you do want more information on a subject, either open the link in a new tab or wait until you and your partner have finished the case and reviewed the check marks. Following the link to the patient note form or the abbreviation list will not interrupt your progress.

History of present illness

• Chief complaint
• I have pain in my chest.
• Location
• The whole left side of my chest.
• Intensity (on a scale from 0–10)
• I would say it is a 7–8 at the moment.
• Quality
• Like someone is stabbing me.
• Onset
• 2 hours ago.
• Precipitating events
• I fell off my bike onto my left side 2 hours ago. I was riding on some wet leaves and slipped as I braked to make a sharp turn. I fell on my chest.
• Progression/constant/intermittent
• It is getting worse.
• Previous episodes
• Never.
• Radiation
• No.
• Alleviating factors
• If I breathe shallowly, it is less painful.
• Aggravating factors
• Taking deep breaths.
• Associated symptoms
• I also feel like I cannot catch my breath.

If a patient complains of shortness of breath, always ask if they would like to assume a different position (e.g., sit up straight) to alleviate the symptom.

Review of systems specific to chest trauma

• Headache
• No.
• Nausea/vomiting
• No.
• Fever/chills
• No.
• Racing of the heart
• Yes, right now at least. But not usually.
• Rash/skin changes (bruises)
• I only have a few scratches on my hands.
• Cough
• No.
• Recent infections
• None.
• Dizziness
• No.
• Loss of consciousness
• No.
• Injury to any other part of the body
• I have a few scratches on my hands, but nothing else.
• Alcohol or drug intake prior to trauma
• No.
• Weakness or numbness
• No.
• Last meal/drink
• About 4 hours ago. I ate some cereal and had a coffee.

Every patient with a history of trauma should be asked about headaches, dizziness, and loss of consciousness to evaluate the likelihood of brain injuries. Ask about all body parts that were injured during the trauma, as the patient might only focus on the main site of injury.

Past medical history, family history, and social history

• Past medical history
• Hay fever.
• Allergies
• Pollen.
• Medications
• Sometimes I have to use a steroid nasal spray and take antihistamines.
• Hospitalizations
• Never.
• Past surgical history
• None.
• Family history
• My father has diabetes.
• Work
• I am a sculptor.
• Home
• I live alone.
• Alcohol
• I drink 1–2 beers per week.
• Recreational drugs
• Never.
• Tobacco
• Yes, I smoke. I have smoked 2 packs a day for 17 years.

• Washed hands
• Used respectful draping
• Body check
  • Scratches on both hands
• Head, eyes, ears, nose, and throat examination
  • Examination of the pupils
  • Examination of extraocular muscles
• Neck examination
  • Evaluation of JVD
• Cardiovascular examination
  • Palpation of the radial pulse
  • Auscultation of the heart
• Chest examination
  • Inspection of the chest
  • Palpation of the chest
    • Tenderness to palpation on the left side of the chest
  • Auscultation of the lungs
    • Painful inspiration, absent breath sounds on the left side of the chest
  • Percussion of the lung fields
  • Examination for fremitus
    • Decreased vocal and tactile fremitus on the left side
• Neurologic examination
  • Examination of orientation to person, place, and time

Patient interaction

• Examinee knocked on the door.
• Examinee introduced him- or herself and identified his/her role.
• Examinee correctly used the patient's name.
• Examinee asked open-ended questions.
• Examinee listened attentively (did not interrupt the patient).
• Examinee showed interest in the patient as a person (i.e., appeared caring and showed respect).
• Examinee demonstrated the ability to support the patient's emotions (i.e., offered words of support, asked for clarification).
• Examinee did not repeat painful maneuvers during physical examination.
• Examinee discussed initial diagnostic impressions with the patient.
• Examinee explained the management plan.
• Examinee used non-medical terms and provided reasons for planned steps in management.
• Examinee evaluated the patient's agreement with the next diagnostic steps.
• Examinee asked about concerns or questions.

Counseling and challenge

• Examinee offered patient counseling on smoking cessation.
• Examinee reacted appropriately to challenge.

Suggested response to challenge: “Let me take a look…Right here are your lungs, on the left you can see a thin line that is not present on the other side of the image. This tells me that your lung has become deflated and collapsed, most likely because some air has gotten between one of your lungs and the space surrounding it, which normally does not contain air. We call this condition a “pneumothorax,” and it is most likely the reason why you have chest pain and are short of breath. The condition could be related to your fall or it could have occurred spontaneously. I would like to run some additional tests to determine the best treatment for you at this time. A nurse will give you oxygen in the meantime so that you can breathe easier. Do you have any other questions?”

Multimedia cases can be challenging. Take your time to look at the image thoroughly and do not pretend to see something pathological that you do not actually see.

Patient note

Differential diagnoses

1. Traumatic pneumothorax: This patient suffered a blunt trauma to the chest when he fell off his bike and is now experiencing stabbing chest pain and shortness of breath. In conjunction with an increased respiratory rate, mild tachycardia, pain on inspiration, decreased breath sounds on the left, and decreased vocal fremitus, this history is consistent with a pneumothorax. Since this patient does not have the typical examination findings of tension pneumothorax (e.g., distended neck veins, reduced chest expansion on the ipsilateral side, hemodynamic instability) and the x-ray shows a pleural line with absent pleural markings on the left side and no tracheal deviation, an uncomplicated traumatic pneumothorax is the most likely diagnosis in this case.
2. Rib contusion: This patient's history of blunt chest trauma followed by chest pain that worsens on inspiration and tenderness to palpation over the left side of the chest suggests a rib contusion or rib fracture. Given the absence of crepitus or a visible fracture line on chest x-ray, rib contusion is most likely here. Subtle rib fractures can be overlooked on a normal chest x-ray and can sometimes only be diagnosed with a rib series x-ray or CT.
3. Spontaneous pneumothorax: In conjunction with this patient's tachypnea, pain on inspiration, decreased breath sounds on the left, and decreased vocal fremitus, sudden-onset stabbing chest pain and shortness of breath suggest a pneumothorax. This patient has multiple risk factors for spontaneous pneumothorax, e.g., male sex, slim stature (BMI of 19.4 kg/m²), and a history of smoking. Moreover, the chest x-ray shows a pleural line with absent pleural markings on the left, confirming the presence of a pneumothorax. However, given this patient's recent history of trauma, a traumatic pneumothorax is more likely in this case.

Diagnostic studies

• Arterial blood gas analysis, pulse oximetry: to assess for acute acid-base disorders (e.g., respiratory acidosis) and whether the patient's blood is sufficiently oxygenated
• ECG: to exclude a cardiac cause of the chest pain; may also provide additional diagnostic clues for pneumothorax
• CT: to further assess for rib fractures and the pneumothorax, to rule out the presence of underlying pathology (e.g., bullae in emphysema), and to determine the likelihood of recurrent disease

Other differential diagnoses to consider

• Rib fracture
• Tension pneumothorax
• Hemothorax
• Pulmonary contusion
• Flail chest
• See also differential diagnoses of acute chest pain and blunt trauma.
• See also differential diagnoses of pulmonary conditions.