Bedside Diagnostic Challenge – 20-year-old college student with chest pain

Paul Griner, MD, MACPBedside Diagnostic Challenge, Internal Medicine, Medical News

Bedside Diagnostic Skills Challenge on chest pain

Today’s Bedside Diagnostic Challenge question comes from the desk of Med-Challenger Internal Medicine Editor-in-Chief, Paul F. Griner, MD, MACP.

Test your bedside diagnostic skills with this review question.


A 20-year-old college student presents to the student health service with the complaint of chest pain. The patient was in good health until 10 hours ago when he developed sudden sharp chest pain while he was trying to open a bureau door that was stuck. The pain is constant but is more pronounced when he leans forward. It is not relieved by lying down or sitting and it has not responded to 600 mg of ibuprofen taken at home. It does not radiate. It has never occurred before. The patient has no symptoms other than the chest pain. He does not smoke, does not take any medications, and denies illicit drug use.

Physical examination reveals a tall thin young man who appears uncomfortable. His temperature is 99.20F, blood pressure in the right arm is 124/74 mmHg, pulse is 92 and regular and respirations are 24/minute. Blood oxygen is 95% on room air. There are no abnormalities on examination of the head and neck. The lungs are clear. Examination of the heart is remarkable for the presence of a rub which is louder on leaning forward. The rub does not change with respiration. Heart sounds are otherwise normal in quality and loudness. There are no abnormalities on examination of the abdomen or extremities. The neurologic examination is normal. You observe puffiness of the soft tissue of the neck and when you palpate the neck, crepitus is noted.

An electrocardiogram shows low voltage but is otherwise normal.


Based on the diagnostic value of careful listening and looking …

What would a chest x-ray of this patient most likely show?

Answer Options:

A wedge-shaped infiltrate in the right middle lobe

A right pleural effusion

Mediastinal lymphadenopathy

Air within the pericardium

Answer Explanation & References:

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About Bedside Diagnostic Challenge:

Except for Hospitalists, Emergency Medicine physicians, and Interventional Cardiologists, most internists will spend the bulk of their professional time with patients in an office setting.

Here is where finely tuned clinical skills are most important in leading to accurate diagnoses, fewer complications resulting from unnecessary tests and procedures, and lower costs. Med Challenger Bedside Diagnostic Challenge reinforces the value of these clinical skills and tests users on their knowledge of them.

Bedside Diagnostic Challenge questions are issued periodically every month as a free content benefit of Med-Challenger.

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About the Author:

Paul Griner MD, MACP graduated from the University of Rochester School of Medicine and completed his residency at the Massachusetts General Hospital, Boston, MA. He returned to Rochester as Chief Resident in Medicine and Hematology Fellow and remained in their Department of Medicine, rising to Professor. He served as a Senior Lecturer at Harvard Medical School and consultant at the Massachusetts General Hospital where he introduced a mentoring program for the faculty of General Internal Medicine.

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