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Sudden Onset Chest Pain in a Young Man

Case Editor - Judd Flesch

Reviewed By Clinical Problems Assembly

Submitted by

Leanne K. Strack, DO

Clinical Instructor and Pulmonary/Critical Care Fellow

The Ohio State University

Columbus, Ohio

James M. O'Brien, MD

Associate Professor of Medicine, Pulmonary/Critical Care Medicine

The Ohio State University

Columbus, Ohio

Submit your comments to the author(s).


An 18-year-old man presents to the emergency department stating he felt like he “was going to die.”  While on break at work, he experienced sudden onset sharp, midsternal chest pain.  He had no dyspnea or radiation of the pain.  He had not suffered any recent chest trauma but did strike his head on a piece of equipment at work without sequelae. Three days prior to presentation he had cough productive of yellow sputum without fevers or chills.  At the time of evaluation, the pain had been present for several hours and was only relieved by narcotic medications.

His past medical history was significant for bipolar disorder, which was controlled without medications.  He worked as a stock clerk at a department store.  He was a current smoker, 1 pack per day for 2 years, and he gave a history of prior cocaine use, but denied any recent illicit drug usage.

Physical Exam

The patient was 69 inches tall and weighed 200 pounds.  He was in no acute distress and was afebrile with an oxygen saturation of 99% on room air.  There was no crepitus on examination.  Lungs were clear to auscultation bilaterally.  Cardiac, abdominal, and extremity examinations were unremarkable.


He had a normal complete blood count, electrolyte panel, and creatinine.  His cardiac enzymes were negative and electrocardiogram (EKG) was normal except for sinus bradycardia.  His toxicology screen was only positive for hydrocodone, which he had been given for pain.


Figure 1. Erect Posteroanterior (AP) Chest Radiograph.

Figure 2. Computed Tomography (CT) Scan of the Chest.

Question 1

What is the most likely diagnosis?


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