Clinical AdvisorClinical Challenge: Young Man with Chest Pain and Numbness in Forearms

🧩 Diagnostic Reasoning Exercise / Teaching Case

A man in his early 30s with no cardiac history presents to the ED with one day of constant, achy chest pain following a week-long upper respiratory infection. Pain does not radiate to the back, is non-pleuritic and non-positional, but is associated with bilateral forearm numbness. Vital signs are notable for blood pressure of 145/83. Chest radiograph is normal. An ECG is obtained; the automated interpretation is non-diagnostic.

Diagnostic Considerations

• Automated ECG software fails to detect acute pericarditis or ACS findings in more than one-third of cases, making independent clinician interpretation essential in any chest pain workup
• ECG findings requiring active clinician review include diffuse concave-upward ST elevation, PR-segment depression, and the Spodick sign — none of which the automated read flagged in this case
• ST-segment elevation greater than 5mm, elevation greater in lead III than lead II, reciprocal depression, or new Q waves should shift suspicion toward MI rather than pericarditis
• CRP is elevated in approximately 80% of pericarditis cases; troponin elevation occurs in 30% at presentation but may lag hours, as it did here, rising from 550 to 5,000 ng/dL on repeat

Practice Pearls

• Recognize pericarditis as a diagnosis of exclusion: ACS, PE, and aortic dissection must be ruled out before committing to the diagnosis, even when ECG findings appear supportive
• Treat confirmed pericarditis with colchicine 1.2mg loading dose followed by 0.6mg once or twice daily for 90 days, with concurrent NSAIDs or aspirin for pain as needed
• Admit when any of the following are present: fever above 101.4°F, elevated troponin, large pericardial effusion, immunosuppression, anticoagulant use, or hemodynamic instability
• Consider uremic pericarditis in at-risk patients, as ECG findings may be especially subtle or absent entirely in this subgroup