A 21 year-old Caucasian male soccer player presented to the emergency room with retrosternal chest pain. The athlete described acute onset of chest pain earlier that morning. The pain radiated into his neck and both arms. It also was associated with nausea, vomiting, presyncope, and diaphoresis. He had been active with the soccer team and denied any prior history of similar symptoms, recent illnesses, or trauma. Past medical/surgical history and family history were unremarkable. He was taking no regular medications and denied the use of recreational drugs or tobacco.
Physical Exam:
On physical exam his blood pressure was approximately 140/90 mm Hg in both arms, pulse 115 per minute, respiration were 32 per minute, and temperature was 99.4 °F. He appeared to be in moderate distress and was unable to lay flat on the gurney. The lungs were clear and auscultation of the heart proved no significant abnormality except for the tachycardia. No murmurs, rubs, nor gallops were appreciated. The rest of the physical exam proved no significant findings.
Initial Differential Diagnosis Based on the History and Physical:
