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

> A respiratory case for medical students: a 25-year-old with sudden sharp chest pain and breathlessness, worse on breathing in. What to ask, red flags, examination, first tests and the differential.

- Respiratory Medicine · Beginner · about 20 minutes
- Web page: https://www.medikarya.in/case-studies/25-year-old-woman-with-sudden-chest-pain-and-breathlessness
- Work up this patient: https://www.medikarya.in/case-studies/25-year-old-woman-with-sudden-chest-pain-and-breathlessness

## How the patient presents

A 25-year-old accountant felt a sudden sharp pain in the right side of her chest while walking to work six hours ago, with breathlessness and a dry cough. The worst has settled, but it still hurts to breathe in deeply.

## 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.

### Heart

- Pericarditis
- Myocarditis

### Lung and pleura

- Pneumothorax
- Pneumonia or pleurisy
- Pulmonary embolism

### Chest wall

- Musculoskeletal pain
- Costochondritis

### Other

- Reflux
- Anxiety, once the others are excluded

## 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.

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A study guide for medical students, not medical advice. Follow your institution's protocols in practice.