May 2008

Submitted by James Short, MD, and Marcel Maya , MD.

History: A 79 year-old female with a past medical history of hypertension, mild renal insufficiency and cervical cancer presented to the emergency room with a complaint of chest pain, duration less than one day. The patient reported that the pain had begun in the back and spread to the shoulders and anterior chest. A chest x-ray was obtained.

Portable chest x-ray shows no cardiac or pulmonary abnormality, but there is a subtle endplate depression in the mid-thoracic spine.

An EKG was performed which showed a right bundle branch block. Troponin levels were obtained; these were within normal limits. The patient was admitted for cardiac monitoring. On admission, a physical examination showed paraspinous tenderness. An MRI of the thoracic spine was obtained.

What is the most likely diagnosis?

A. Myocardial infarction
B. Pulmonary embolism
C. Herpes Zoster
D. Vertebral compression fracture
E. Pneumonia

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