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My chest hurts!

A 21-year-old male patient presented to ED with a few hours' history of right-sided vague chest pain.

He is normally fit & well.

Normal vital signs except mild tachycardia.

No further clinical information is available.

Here is the ECG of this patient,

What is the Differential Diagnosis (D.D) of this patient?

How will you work the case up to reach the final diagnosis?


This was an interesting case that I had seen a few years ago & I wanted to share it with you as it has interesting findings that not all of us are aware of. It will also be a good chance to share with the EM beginners the thought process I would suggest you follow when faced with a complex case.

Let's start by analysing the clinical presentation:

Young male + non-specific chest pain + ECG with ST elevation

I know this is not enough at all to reach a final diagnosis, but those of you who work in Emergency Departments (EDs), especially in the UK, get this all the time when the nurses ask them to sign ECGs for patients they haven't seen with limited information, so this is not far from real.

Let's start by putting a Differential Diagnosis (D.D.), then we can work our way through it.

Here are the possibilities:

  1. STEMI.

  2. Pericarditis.

  3. Benign Early Repolarization (BER).

  4. Pneumonia.

  5. Pulmonary Embolism (PE).

  6. Aortic dissection.

  7. Pneumothorax.

This was the D.D. that was made for the above case.

Let's analyse the D.D.:

  • Pneumonia is the easiest to rule out as the clinical presentation doesn't fit, & the ECG doesn't fit, so no tricks here, it is NOT pneumonia.

  • STEMI will always be a possibility in any presentation like this. I will take the chance to encourage you to always consider the possibility of a STEMI in any case with chest pain & an ECG that shows ST elevation REGARDLESS the age, risk factors, & shape of the ST segment. In this particular case, the pain didn't sound cardiac at all, so this moved the STEMI to be far down in the D.D.

  • Pulmonary Embolism (PE) was ruled out clinically using the Wells' score & the PERC score.

  • Benign Early Repolarisation (BER) was ruled out by finding an old ECG with no ST elevation, which means that the changes we had that day were all new.

  • Aortic dissection was planned to be ruled out via a chest X-ray + echo + D-dimer, as the patient didn't have any risk factors for it.

Now, we are left with acute pericarditis & pneumothorax.

Let's analysis the ECG:

To be honest, the ECG shows many signs of acute pericarditis (diffuse saddle shape ST elevation, Spodick's sign, PR elevation in aVR, PR depression in many other leads), so this was the initial diagnosis of the case.

But the chest X-ray that was done as part of the workup of the patient came back with a surprise!

This was a case of PNEUMOTHORAX!

ECG changes with pneumothorax:

I couldn't find a lot written on this topic other than some sporadic case reports (I will add in the reference section), so here is the summary of what I found:

ECG changes with left-sided pneumothorax:

1) Right axis deviation.

2) Loss of R wave progression in V1-6.

3) Low voltage ECG.

4) T wave inversion in V1-6.

5) PR elevation/depression.

6) ST elevation/depression.

Here is another good example of a left-sided pneumothorax ECG that shows many of the above findings.

Courtesy to Dr. Rachel Harrison, Emergency Medicine Consultant, UK.

ECG changes with right-sided pneumothorax:

1) Loss of R wave progression in V1-6.

2) Q waves in inferior leads.

3) ST elevation (No ST depression has been reported with right-sided pneumothorax).

Mechanism of ECG changes:

1) Cardiac rotation/displacement (axis deviation).

2) Right ventricular (RV) dilatation.

3) The insulating effect of the air between the heart & the chest wall (low voltage ECG).

So, although the ECG of the case didn't show all the classic findings of pneumothorax, I thought it is a good one to add one more possibility for chest pain patients with ST-elevation to your D.D.

I hope you find this useful.

Best of luck.

For references & further readings:

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01. Juli
Mit 5 von 5 Sternen bewertet.

very nice case, thanks for sharing.

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27. Juni
Mit 5 von 5 Sternen bewertet.

Well explained,

Thanks for information.

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Antwort an

You are welcome. Thanks for the supportive comment.

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Mit 5 von 5 Sternen bewertet.

Thanks for sharing.

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Antwort an

You are most welcome 😊

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Mit 5 von 5 Sternen bewertet.

Thanxs Dr. Hesham

nice ,good explanation 🙏🙏🙏🙏

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Antwort an

You are welcome. Glad that you found it useful 😊

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