Chest, Breast and Ribs

Question 1

What are the possible causes of chest pain based on embryologic development and multi-segmental innervation?

Answer 1

Possible causes include

• chest wall dermatomes (T1-T12)
• trachea and airways
• lungs, mediastinum, and viscera due to shared embryologic origins

Question 2

How should past medical history be utilized in evaluating chest pain?

Answer 2

While past medical history cannot rule out medical causes alone, it provides information about increased risk and guides the screening process for systemic vs. neuromusculoskeletal causes.

Question 3

What are the primary risk factors for cardiovascular causes of chest pain?

Answer 3

Risk factors include gender (higher in males until menopause in females), age, family history, hypertension, CAD, hyperlipidemia, and race (higher in African Americans, Mexican Americans, Native Americans).

Question 4

What are the key signs that differentiate cardiac pain from non-cardiac pain?

Answer 4

Cardiac pain is often precipitated by exercise, lacks musculoskeletal findings, and doesn’t present with the 3 P’s (pleuritic, positional, or palpable pain).

Question 5

What is the clinical presentation of pleuropulmonary causes of chest pain?

Answer 5

Symptoms include dyspnea, pain that increases with respiratory movements, coughing, and relief by auto-splinting or sitting upright.

Question 6

What gastrointestinal conditions can present as chest pain, and how do they manifest?

Answer 6

Conditions like esophagitis, ulcers, pancreatitis, and hepatic disease may present with anterior chest pain, epigastric pain, or pain radiating to the back, often influenced by food intake or antacid use.

Question 7

How does a history of cancer affect the screening for chest pain of oncological origin?

Answer 7

A history of cancer is a red flag as metastases to the pulmonary system are more common causes of chest pain than primary cancers of the chest wall.

Question 8

What are the risk factors for breast cancer in males and females?

Answer 8

Females: family history, age (60-61), Caucasian race, BRCA mutations, high breast density. Males: family history, age (60-66), Klinefelter syndrome, obesity, radiation exposure.

Question 9

What are the key clinical signs of breast cancer that might present as chest or breast pain?

Answer 9

Signs include breast mass, retraction, axillary mass, scaly nipple, edema, and tenderness, along with lymph node abnormalities in the supraclavicular and axillary regions.

Question 10

How can anxiety present as a cause of non-cardiac chest pain?

Answer 10

Anxiety-related chest pain is often dull, aching, and substernal. It doesn’t change with activity or palpation and is associated with stress or depression.

Question 11

What are the musculoskeletal causes of chest pain that must be differentiated from cardiac pain?

Answer 11

Musculoskeletal causes include costochondritis, Tietze’s syndrome, slipping rib syndrome, hypersensitive xiphoid, and trigger points.

Question 12

How do costochondritis and Tietze’s syndrome differ in presentation?

Answer 12

Costochondritis involves sharp pain without swelling, affecting older adults, while Tietze’s syndrome has localized swelling and affects younger individuals or children.

Question 13

What are the clinical features of slipping rib syndrome?

Answer 13

Pain exacerbated by slumping or side bending, often linked to rib hypermobility. It must be differentiated from gallbladder pain through food-related symptoms.

Question 14

How does intercostal neuritis, such as herpes zoster, present in the context of chest pain?

Answer 14

Intercostal neuritis presents with severe pain followed by a vesicular rash along a dermatome, typically not crossing the midline.

Question 15

What differentiates dorsal nerve root irritation in the thoracic spine from cardiac pain?

Answer 15

Dorsal nerve root irritation causes superficial chest wall pain that worsens with upper extremity movements, not related to lower extremity activity.

Question 16

What are the red flags for chest pain indicating possible anemia?

Answer 16

Signs include fatigue, pallor, and changes in vitals. Questions about unusual bleeding or NSAID use are important follow-ups.

Question 17

How can breast implants lead to chest pain, and what are the associated risk factors?

Answer 17

Breast implants, especially after mastectomy, can cause chest pain due to scar tissue or reaction to the implants.

Question 18

What is the hallmark of trigger points (TrPs) in musculoskeletal chest pain?

Answer 18

Trigger points often involve pectoral muscles and can be a result of previous myocardial infarctions or repetitive strain.

Question 19

How can cervical spine disorders mimic chest pain?

Answer 19

Cervical spine disorders cause pain with neck movements that can radiate to the chest or arm, worsening with recumbency, unlike cardiac pain.

Question 20

How should you approach screening for chest pain of hepatic or pancreatic origin?

Answer 20

Look for abrupt pain onset in the upper abdomen, RUQ tenderness (hepatic), or symptoms relieved by antacids (pancreatic).

Question 21

What are the common signs of thoracic outlet syndrome in the context of chest pain?

Answer 21

Thoracic outlet syndrome presents with pain in the neck, shoulder, or chest area, often aggravated by upper limb movements.

Question 22

What risk factors are associated with stimulant-induced chest pain?

Answer 22

Use of cocaine or anabolic steroids can lead to CVA, BP changes, dyspnea, and longer healing times for injuries.

Question 23

What is the clinical significance of aortic aneurysms in relation to chest pain?

Answer 23

Aortic aneurysms typically present with chest pain that is not isolated and may be associated with pulsatile masses or hypotension.

Question 24

Why is it crucial to differentiate chest pain caused by rib fractures from that of cardiac origin?

Answer 24

Rib fractures cause sharp, localized pain associated with trunk movement, while cardiac pain is more diffuse and positional.

Question 25

How does the clinical presentation of GI-related chest pain differ from musculoskeletal chest pain?

Answer 25

GI pain often changes with food intake and remains unaffected by musculoskeletal palpation or posture changes.

Question 26

What signs suggest that chest pain may be related to breast cancer rather than a musculoskeletal issue?

Answer 26

Presence of breast masses, lymph node changes, or skin abnormalities like edema or retraction point to a cancer origin.

Question 27

How does age impact the risk of developing musculoskeletal conditions like Tietze’s syndrome?

Answer 27

Tietze’s syndrome typically affects younger individuals aged 20-30, while costochondritis is more common in those aged 40 and older.

Question 28

What is the role of systemic signs in differentiating chest pain of oncological origin?

Answer 28

Systemic signs include dyspnea, weight loss, unexplained fatigue, and persistent cough indicative of metastases rather than a primary musculoskeletal cause.

Question 29

What are the key features of sternalis syndrome as a cause of chest pain?

Answer 29

Sternalis syndrome involves pain and tenderness over the sternalis muscle, often mistaken for cardiac or musculoskeletal issues.

Question 30

How does hepatic disease manifest as chest pain?

Answer 30

Hepatic disease causes RUQ tenderness, referred shoulder pain, and possible systemic symptoms like jaundice.

Question 31

Why is screening for neurological causes of chest pain important, and what conditions should be considered?

Answer 31

Neurological causes like dorsal nerve root irritation and intercostal neuritis must be considered due to their overlapping symptoms with cardiac pain.

Question 32

How does chest pain from oncological causes differ from other types of chest pain?

Answer 32

Oncological chest pain often includes systemic symptoms, painless palpable masses, and skin changes indicative of malignancy.

Question 33

What screening techniques can help differentiate between neuromuscular and cardiovascular chest pain?

Answer 33

Techniques include assessing for neurological signs (e.g., tingling, numbness) and comparing the effects of activity on pain.

Question 34

How should rib hypermobility be assessed in the context of chest pain screening?

Answer 34

Assess for pain exacerbated by trunk movements or side bending, distinguishing from visceral causes like gallbladder issues.