Elderly man with sudden onset chest pain

A 69-year old retired man was brought to the Emergency Department because of a sudden onset of left-sided chest pain and dyspnea. The pain was exacerbated by inspiration. He complained of a cough, but hemoptysis did not occur. He was taking no medications and had been in good health, except recently he had noted mild dyspnea on exertion and had to use two pillows at night to sleep comfortably.

Physical examination revealed a slightly obese man in moderately acute distress. The cardiac rate was 98/min, the respirations 32/min, blood pressure was 158/106 mm Hg, and temperature 99.6^o F. There were no heart murmurs on auscultation. There were soft rales at both lung bases, more marked on the left side. A friction rub was heard at the base of the left lung in the mid-scapular line. On examination of the legs, the left leg was found on measurement to be slightly larger in circumference than the right. An electrocardiogram showed a normal sinus rhythm. A chest X-ray showed a pyramidal shaped area of increased density at the left posterior base with the base of the pyramid located on the pleural surface.

The correct answer is D. Pulmonary embolus. There were a total of 11 responses. A breakdown of responses are inside the parentheses below.

The most likely diagnosis is:

A. Phlebothrombosus (1)
B. Dissecting aortic aneurysm (0)
C. Myocardial infarct (1)
D. Pulmonary embolus (6)
E. Congestive heart failure (3)

(see results graphically)