A Complex Cause of Pleuritic Chest Pain

A CLINICAL PROBLEM-SOLVING article by Lindsay King from Brigham and Women's Hospital, Boston.
A 33-year-old man presented to the emergency department with pain in the right side of his chest that started 5 days earlier. It originated near his right shoulder blade and radiated throughout his right chest. The pain was worse with deep inspiration and when he was lying down. He also noted mild swelling of his lower legs during the past several weeks. He had mild tachycardia and hypertension. The patient had a history of ulcerative colitis, which had been diagnosed 4 years earlier. He also reported that both his children had contracted streptococcal pharyngitis 1 month earlier.
The clinical evaluation should initially determine whether there is a potentially life-threatening cause of chest pain, including pulmonary embolus, acute coronary syndrome, aortic dissection, or tension pneumothorax. The patient's chest pain worsens with deep inspiration and recumbency, which suggests either a pleuritic cause or a musculoskeletal cause.
An interactive medical case associated with this article is available at NEJM.org [Original Article]

静脈血栓症、膜性腎症、原発性硬化性胆管炎、過敏性大腸症候群の織りなす事例。疫学の世界では、むしろ単一の原因が求められることは稀だが、いざ臨床の場にあると、単一原因を見つけてしまうと安堵して他の原因を見逃してしまうことは往々としてある。特に、医療に限らずカタストロフィは複合要因によって招かれることは肝に銘じておきたい。