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Clinical Case 071: Chest pain puzzle

OK a quick case for you – a diagnostic case for you to ponder.  No critical care this week!

36 yo man presents to the GP with a 3 day history of increasing, sharp, pleuritic posterior chest pain that has a clear mechanical history.   It began the morning after a long play session in he pool with his kids throwing them up in the air / twisting and lifting.

Pain is localised over the T6 – 7 level, just lateral to the spinous processes.

Chest is clear, no cough, URTI sxs or signs, feels well aside from pain which is making breathing unpleasant.

On examination there is tenderness to the area described above. Range of movement is markedly reduced – limited by pain on lateral and forward flexion.  Rotational movement of the spine is limited by pain right more than left.

So here are the questions:

Q1:  What is the diagnosis most probably?

Q2:  What investigations would you do?

Q3:  Which medicines or other therapies would you advise / prescribe?

 

Comments

  1. Q1. Sounds like costovertebral joint dysfunction
    Q2. If was in ED, you might consider an ECG and a CXR (but sounds unlike LRTI), although the risk is there for him to develop one with poor insp effort while the pain is there!
    Q3. NSAIDs (if no contraIx) or alt analgesia to permit deep breathing, some gentle physio.

    • Hi Gerry
      Yes -- costovertebral joint dysfunction -- spot on with the diagnosis. Refreshing to see an actual diagnosis rather than “Musculoskeletal” or the ED equivalent “not cardiac chest pain”.

      History and exam all say it is from the chest wall and clearly mechanical -- so pretest probability for even an ECG is low, still can do it -- but interpret it with caution in such a stuation. A subtle ST change s likely a re-herring.
      No CXR here for me -- sems very unlikely to help

      NSAIDS- might help, but not really in my experience. Physio is the solution, education, assurance and a plan re: stretching, musce rehab and getting it moving.
      This iis one area where Docs often fail their patients -- we have not got much to offer unless we have a specific interest in manipulation etc.

      FYI -- phyysiotherapy was veryuseful -- the patient in wquestion manage to complete a full daylist of nerveblocks and tubes without crying!
      C

      • I remember breaking my left 5th pinky doing an anaesthetics term. Bag and masking, not fun! Thanks for the feedback. I wouldn’t have done a CXR either, but very interesting about NSAID non-effect.

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