Chest pain

Chapter 21 Chest pain



Case 21.1



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

Right-sided pneumothorax (probably spontaneous, closed type). Justification:


• sudden onset of acute dyspnoea and chest pain, with no prior episodes, indicates an acute event in an otherwise well person

• unilateral chest pain which is worse on inspiration is likely to be a ‘pleuritic’ type pain; that is, the pleura is involved in the pathological process, or possibly a pericardial pathology which is irritating the adjacent pleura

• right-sided hyper-resonance indicates that there is excess air in either pleural cavity or the lung field on that side

• decreased breath sounds on the right side suggests that either:
image there is less air entering the alveoli or

image there is decreased transmission of sound.

Conclusion: there is an increase in the volume of air unilaterally. Considering his clinical presentation, the excess air is most likely located within the pleural cavity rather than the lung (ie: a pneumothorax). All other clinical features support this diagnosis.


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

A pneumothorax in a young healthy male is usually a result of the rupture of a sub-pleural bulla (usually a congenital lesion). It releases a finite amount of air, and is thus self-limiting.


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

Chest X-ray in both inspiration and expiration.


4. Name and describe the categories of the disorder identified in question 2.

Spontaneous — closed


• The flow of air between the pleura and the lung seals off as the lung collapses and does not reopen. The air is gradually reabsorbed by the lung tissue and the lung re-inflates.

Spontaneous — open


• The opening is generally with a bronchus and does not close off when the lung collapses. The air pressure in the pleural space becomes more like that of the atmosphere, and the lung can’t re-expand. The possibility of infection is high.

Valvular or tension


• The opening between the pleura and the lung persists and acts as a one-way valve, allowing air into the pleural cavity, but not out. Air pressure builds up quickly, causing collapse of the lung and compression of the other lung. Death occurs if untreated.


Case 21.2



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

No — it is an incorrect misconception that heart pain is located on the left side of the chest. It is most commonly central in position.


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

Angina pectoris — his symptomatology is classic ischaemic heart disease. Reasons are:


• the quality of pain (ie pressure or tension)

• the pain occurs when he goes to the gym (increase in physical exercise)

• it is relieved a few minutes after he stops to rest

• he has predisposing factors for ischaemic heart disease (hypertension, obesity).

There is a small possibility that his pain is related to his musculoskeletal system, but the pattern of pain is not typical.


3. You refer Doug to a medical practitioner. What investigations are required?
• Electrocardiogram (ECG)—at rest and with exercise.

• Lipid studies: cholesterol, high-density lipoproteins (HDLs), low-density lipoproteins (LDLs) etc.

• Depending on the results of the ECG, Doug may require coronary computed tomographic angiography (CTA), which will identify areas of coronary artery narrowing.


Case 21.3



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

The likely differential diagnosis is:


• hiatus hernia

• gastro-oesophageal reflux disease (GORD).

Recurrent episodes over 6 months suggest a chronic condition. Burning retrosternal chest pain related to eating suggests an oesophageal problem (the description is not one of ischaemia or pleuritic involvement). It is worse at night in bed, and with bending over. This suggests a ‘gravity’ related event, and hence a gastro-oesophageal reflux problem is likely.


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

In both disorders, there is dysfunction of the gastro-oesophageal junction. As a result, there is reflux of gastric content from the stomach and into the oesophagus. The acid content stimulates pain receptors in the oesophagus, causing pain.


With bending over and when lying in bed, the change in position and the effect of gravity makes it easier for reflux to occur. Symptoms are worse following a meal due to the increase in gastric content.


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

Barium studies of oesophagus and stomach or endoscopy (oesophagogastroduodenoscopy). If necessary, oesophageal manometry and 24-hour pH testing.


4. Name possible complications of Leo’s condition.

Complications may include:


• oesophagitis and possible stricture formation in the oesophagus, resulting in dysphagia

• oesophagitis may cause slow bleeding and possible anaemia

• less commonly there may be aspiration of regurgitated fluid into the airways

• with a large hiatus hernia, there may be pressure placed on thoracic structures, causing dyspnoea and/or coughing.


Case 21.4



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

Intercostal myositis. Justification:


• 2. day duration of pain indicates an acute problem.

• Pain worse with movement and muscles tender on palpation indicate a musculoskeletal problem.

• Diffuse distribution of pain indicates that many areas of muscle are probably involved.

• History of an URTI suggest a possible diagnosis of myositis.

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

No — there is no indication that there is a serious cause for her symptoms. If the symptoms persist beyond a few days, or if there is a change in her clinical presentation, then referral may be needed.


3. Could her earlier illness be related?

Myositis is commonly preceded by an URTI.



Case 21.5



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















Possible diagnosis Justification
Musculoskeletal problem
• This is the most likely cause of chest wall pain

• Sharp pain which is easy to localise, aggravated by body wall movements such as coughing or movement, all suggest a somatic origin

• A plausible cause (from vigorous coughing or pushing a heavy machine)
Pleurisy
• A history of concurrent or recent URTI

• The patient feels tired, perhaps indicating systemic involvement

• It is a sharp pain aggravated by chest wall movement
Fractured rib
• A sharp, easy to localise pain aggravated by body wall movement

• If she has a history of long-term corticosteroid use for her asthma, this could potentially render her osteoporotic

• A plausible cause of fracture is forceful coughing in a woman who is possibly osteoporotic

2. Why was Carly asked about:
a medication

Inquiring as to a patient’s current and previous medication is a standard and required component of the case history process. The effects of adverse or intended medication may both account for the patient’s complaints, as well as represent a contraindication to your care. In this case, the long-term use of corticosteroids and a predisposition to osteoporosis must be considered.


b a recent history of URTI

Carly complains not only of chest pain but of a recent respiratory illness. She also appears pale and feels tired, alerting the practitioner to the possibility of a non-mechanical cause to her symptoms. On this basis, the practitioner should consider the possibility of a link between her recent illness and her current chest wall symptoms.


3. What are the most pertinent physical examination procedures to be undertaken in this case? Justify your choices.
• Thoracic spine examination—mechanical problems of the ribs and thorax are the most likely source of chest wall pain.

• Chest (lungs and thorax) examination—her recent illness and the location of the pain require this.

• Vital signs—she feels tired and appears unwell.

• Lymph node assessment.

• Oral cavity and throat examination for signs of current infection.

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

The absence of fever suggests no active infection is present. The absence of significant pain upon firm percussion of regional skeletal structures suggests that a fracture or significant bone disease is not present. A dull percussion note suggests the presence of either fluid or a solid mass in the lung. Crackles may indicate the presence of fluid or mucous in the alveoli, particularly if heard during inspiration. Alternately, crackles are also heard in fibrosing alveolitis. A sound resembling crackles heard across both inspiration and expiration suggests the presence of a pleural friction rub.


5. What is the most likely diagnosis? Justify your choice.

The most likely diagnosis is pleurisy. Whilst the description of the character of pain suggests a somatic origin, the presence of chest (lungs and thorax) findings suggests pleuritic involvement. Typical of pleurisy is a recent or concurrent history of respiratory infection, although less common causes of pleurisy can also occur.


6. What do you feel is the appropriate immediate management for this patient?

If pleurisy is suspected, the patient should be referred to a medical practitioner.


7. What further tests or investigations should be performed?

Whilst the most likely cause is idiopathic pleurisy associated with her respiratory tract infection, it is important to both investigate the extent of this and to rule out other causes of pleurisy, so that any underlying disorder can be identified and treated. Typically, a chest radiograph would be taken to initiate the investigation. Other procedures such as computerised tomography and ultrasonography may be undertaken depending on the clinical presentation and course of the illness. In some cases, thoracentesis (removal of a sample of the pleuritic fluid), may be employed. Serious conditions such as autoimmune disorders (eg: systemic lupus erythematosus [SLE] or rheumatoid arthritis), tuberculosis and cancers (eg: mesothelioma and lymphoma) may cause pleurisy.


8. What has produced the chest findings?

A fibrinous fluid has been produced and is now evident in the pleural space. This accounts for the flatness/dullness to percussion. The two pleural layers tend towards adhering together which produces what is described as a squeaking, rubbing or crackling sound upon auscultation and throughout inspiration and expiration. It is important to note that the area of pleurisy producing these signs can be very small, thus examination needs to be conducted with particular attention to detail if pleurisy is suspected.


9. Discuss the relevance to physical therapists of the disorder identified in question 5.

The symptoms of pleurisy may mimic those produced by mechanical problems of the thorax. The parietal pleura is innervated by somatic sensory fibres. Thus, when irritated, it produces a pain similar to that produced through irritation of body wall structures. It is important for practitioners to distinguish between these two causes of chest wall pain.


10. What is the most likely outcome for Carly?

Providing there are no serious underlying conditions which have contributed to Carly’s pleurisy, she should make a full recovery over a period of 2–4 weeks. In most cases, pleurisy resolves without specific treatment and management is palliative.



Case 21.6



1. Using only this information, list the possible causes of Alison’s pain. Justify your answer.














Possible diagnosis Factors supporting diagnosis Factors not supporting diagnosis
DDX 1: musculoskeletal condition
• Exacerbation of pain with deep inspiration, sneezing and trunk movement

• History of unaccustomed activity (moving furniture)

• Tenderness over local sternal region

• Pain is localised

• Nature of pain: sharp with movement
  
DDX 2: cardiac condition
• Must be ruled out

• Chest pain

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Dec 26, 2016 | Posted by in MANUAL THERAPIST | Comments Off on Chest pain

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