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Chest Pain with Diffuse T-Wave Inversion

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Am Fam Physician. 2014 Aug 15;90(4):257-258.

A 45-year-old man presented with worsening left-sided, sharp pleuritic chest pain that began one week earlier. The pain started after a few days of dry coughing. It was initially located at the lateral chest wall, then spread to the midsubsternal area and the left axilla. The pain was associated with exertional shortness of breath and dizziness. The patient did not have fever, chills, sputum production, diaphoresis, recent travel, or cold-like symptoms. He had a history of hyperlipidemia and a hiatal hernia. He smoked one pack of cigarettes per day and was obese.

Physical examination revealed no acute distress at rest. Vital signs were unremarkable except for a pulse of 108 beats per minute. His oxygen saturation level was 94% on room air. Lungs were clear to auscultation bilaterally. There was no chest wall tenderness. Auscultation showed a regular rhythm with a third heart sound. There was no peripheral edema or tenderness in the lower extremities on palpation. Electrocardiography (ECG) was performed (see accompanying figure).



Based on the patient's history, physical examination, and ECG findings, which one of the following is the most likely diagnosis?

A. Acute coronary syndrome.

B. Gastroesophageal reflux disease.

C. Pericarditis.

D. Pleuritis.

E. Pulmonary embolism.



Author disclosure: No relevant financial affiliations.

Address correspondence to Brian Shian, MD, at Reprints are not available from the authors.


1. Wilbur J, Shian B. Diagnosis of deep venous thrombosis and pulmonary embolism. Am Fam Physician. 2012;86(10):913–919.

2. Walder LA, Spodick DH. Global T wave inversion. J Am Col Cardiol. 1991;17(7):1479–1485.

3. Meisel JL, Cottrell D. Differential diagnosis of chest pain in adults [password required]. January 7, 2013. UpToDate. Accessed May 23, 2014.

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