Chapter 21 Chest pain

Case 21.1

Nick is a 20-year-old male who presents with a sudden onset of right-sided chest pain and acute dyspnoea, which commenced as he was watching a game of football. The pain is worse on inspiration. He is otherwise well, and has never suffered from these symptoms before. There is no history of trauma.

On examination, there is a hyper-resonant percussion note on the right side. On auscultation, there were normal breath sounds in the left and most of the right lung fields, but in some areas of the right lung field, no sounds were heard at all.

Questions

1. What is the most likely diagnosis? Justify your answer.

2. What is the most likely reason a healthy young man would develop this condition?

3. You refer Nick to a medical practitioner. What investigation does he need to confirm the diagnosis?

4. Name and describe the categories of the disorder identified in question 1.

Case 21.2

Doug is a 45-year-old man who consults you about recurrent pain episodes he is getting when he goes to the gym. He says that they are in the centre of his chest rather than the left side, so he feels confident that it is not related to his heart. He believes that they may be related to the muscles he is using when he lifts weights, because the pain feels like a pressure or tension in his chest. He is overweight, and is trying to get fit, but this problem has resulted in a progressive shortening of his workout. The episodes are not accompanied by dyspnoea. When they occur, he needs to stop the session and wait about 5 minutes before the pain goes away. Doug says he tries to be careful during these sessions, because he knows his blood pressure is ‘a bit high’, for which he takes medication.

Questions

1. Do you agree with Doug’s ‘self diagnosis’ that his pain is unlikely to be related to his heart? Why or why not?

2. What do you believe is the most likely diagnosis? Why?

3. You refer Doug to a medical practitioner. What investigations are required?

Case 21.3

Leo is a 52-year-old man who presents with a 6 month history of recurrent episodes of retrosternal chest pain, which he describes as a ‘burning’ sensation. The pain seems to be worse after meals, at night when lying in bed, and when he bends over to pick something up.

Questions

1. What is your differential diagnosis? Justify your answer.

2. How does the pathology of each of these disorders result in the symptoms Leo has described?

3. You refer Leo to a medical practitioner. What investigations are required to confirm your diagnosis?

4. Name possible complications of Leo’s condition.

Case 21.4

A 20-year-old woman presents with a 2 day history of non-specific, diffuse chest pain. She states that sometimes it feels sharp, although at other times it feels ‘tight’. It is worse when she moves, but normal breathing at rest does not seem to affect it. She has also noticed that when she touches her chest between the ribs, it feels a little sore. She recently has had an upper respiratory tract infection (URTI).

Questions

1. What is your differential diagnosis? Justify your answer.

2. Do you need to refer her? Give reasons for your answer.

3. Could her earlier illness be related?

Case 21.5

History

Carly is a 34-year-old woman who presents with back pain, and points to the right posterior chest wall to show you the region of her discomfort. She explains that over the last 2 days the pain has intensified to the extent that she finds it difficult to take a deep breath and to cough, the latter of which she has been doing a lot over the past few weeks whilst battling a ‘bout of flu’.

Carly feels as though she may have pulled a muscle in her back, as movement seems to aggravate what she describes as a sharp pain. She thinks that this may be due to her recent coughing, or her work as a cleaner pushing a large polishing machine.

Upon questioning, Carly states that she still feels quite tired from having the ‘flu’ although she does not seem to be bringing up as much phlegm as she was a week ago. She reports no history of trauma or accident. Upon further questioning, she tells you that she has had chronic asthma since the age of 11, and that she has taken regular medication for this condition for the past 20 years.

Questions

1. What is your differential diagnosis for Carly’s pain? Justify your choices.

2. Why was Carly asked about:

a medication?

b a recent history of URTI?

3. What are the most pertinent physical examination procedures to be undertaken in this case? Justify your choices.

Physical examination

General	Carly is a short, thin woman who appears to be in discomfort
Vitals	•Pulse rate/min	98
	•Respiratory rate/min	20
	•Blood pressure mm Hg	118/78
	•Height (cm)	150
	•Weight (kg)	48
	•BMI	21.3
	•Temperature (degrees C)	37.1
HEENT	Unremarkable
Neck	No lymphadenopathy
Chest	During auscultation, a scratchy sound is heard, located in the mid axillary line at the level between the 6th and 8th ribs. A dull percussion note is also evident over this region, which is approximately 3cm in diameter
Abdomen	Soft, non-tender, no masses
Back	A scoliosis is present. The right side of the thoracic spine palpates as tight and tense. Range of motion is limited and painful when the patient laterally flexes to the left-hand side. Firm percussion over the ribs and spinal segments throughout the painful region produces no pain

Questions

4. What information can you obtain from these findings? Can you narrow your differential diagnoses? Explain why.

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