Sudden sharp chest pain and breathlessness in a 25-year-old: a case to work up

Why sudden pleuritic chest pain in a young adult matters

Sharp chest pain that catches on breathing in a young, otherwise well person is often benign, but a collapsed lung or a clot in the lung must be found. The story of the onset, her risk factors, the examination and a chest X-ray sort out most of them.

What to ask in the history

• How it started and what she was doing
• Where the pain is, what it feels like, worse on breathing or moving
• Breathlessness, cough, coughing up blood, fever
• Previous episodes
• Smoking of any kind
• Contraceptive pill, pregnancy, recent travel or immobility, leg swelling
• Family history of clots
• Recent injury

Red flags

• Breathlessness getting worse
• Low oxygen saturation
• Fast pulse or low blood pressure
• The trachea pushed to one side
• Coughing up blood
• A swollen, tender leg

What to examine

• Observations
• Trachea, chest expansion
• Percussion and breath sounds on each side; a rub
• Tenderness of the chest wall
• Heart sounds
• The legs

First investigations

• Chest X-ray
• Oxygen saturation, blood gas if low
• ECG
• Pregnancy test
• A clinical probability score, then D-dimer or imaging as it directs
• Full blood count and CRP if infection is possible

Differential diagnosis of sudden pleuritic chest pain in a young adult

Grouped, not ranked. Which one fits this patient is for you to work out in the case.

Common mistakes

• Calling it a muscle strain without a chest X-ray.
• Sending a D-dimer on everyone instead of judging probability first.
• Forgetting the pregnancy test.