Severe chest pain in an asthmatic patient

A 20 year old woman with a history of asthma presented to the emergency department complaining of shortness of breath and sharp pains in her chest and neck. The pain was worse on deep inspiration. She had a cough which produced small amounts of whitish sputum. The patient had had several previous exacerbations of asthma, and recently had not been using her inhalers regularly. On examination, her airway was patent and she had a generalised moderate wheeze in her chest, but no other obvious clinical signs. She could speak in full sentences and had normal oxygen saturations and temperature. She was mildly tachycardic and appeared slightly anxious. Her blood tests showed a mild neutrophilia and elevated C reactive protein. She was given salbutamol and ipratropium nebulisers. These improved her wheezing, but she still complained of a severe central chest pain. In light of the unresolved chest pain and raised inflammatory markers, a chest radiograph was performed (fig 1⇓) Fig 1  Chest radiograph