Sudden-Onset Chest Pain in an 80-Year-Old Man With COPD

Samantha Nicholson-Spence, MB BS; Frederick Williams, MD

Disclosures

January 08, 2019

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to recognize accurately. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.

Background

An 80-year-old man presents to the emergency department (ED) with a 2-day history of right-sided chest pain. The pain was sudden in onset, is constant, and is exacerbated by coughing and deep inspiration. He reports baseline shortness of breath secondary to bronchiectasis, chronic obstructive pulmonary disease (COPD), and congestive heart failure with New York Heart Association (NYHA) class III function. His dyspnea has not worsened since the onset of his pain.

He had a worsening cough 1 week ago, with brown sputum, and noted low-grade temperatures of 99°F to 100°F (37.2°-37.7°C). He took ciprofloxacin for these symptoms, which resulted in a return to baseline. He does not use bronchodilators because he reports that they are "difficult to tolerate." He performs postural drainage twice daily and takes guaifenesin 4 times daily. He denies having any fever, chills, or hemoptysis.

He has no history of exposure to tuberculosis. He denies experiencing any leg swelling or calf pain, but he does have a past medical history significant for deep vein thrombosis and pulmonary embolism 4 months prior to this admission, for which he takes warfarin. He has never smoked and has no history of occupational exposures. No one in his family is affected by lung disease.

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