Case 13--Acute Chest Pain in a Middle-Aged Man

Clinical summary: A 50-year-old, previously healthy mechanic and carpenter developed severe, pleuritic chest pain that radiated across the chest to both shoulders 12 hours after smoking crack cocaine. The pain awoke him acutely at 4 am. It was not relieved by eating. He also noted mild dyspnea but no nausea, sweating, dizziness, or syncope. There was no limb numbness or weakness. He had no leg pain or swelling. Fever, chills, and anorexia were absent, but there had been a 35-50 lb weight loss over the previous year. There was no history of coronary artery disease or cancer. On admission, he was in moderate pain and afebrile, with heart rate 110/min, respiratory rate 13/min, and BP--R arm 178/105, L arm 161/100 mm Hg. Pulses were equal bilaterally, and there was no jugular venous distension. Oxygen saturation was 96% on room air. Lungs were clear, and the cardiac examination was unremarkable. The remainder of the examination was normal. A chest radiograph showed possible widening of the mediastinum but no pulmonary edema, masses, lymphadenopathy, or effusions.

Which procedures are indicated?

Radiology | Image 1 | Image 2 | Image 3 | Image 4 | Image 5 | Discussion

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