DIFFERENTIAL DIAGNOSIS for

PHYSICAL THERAPISTS
Screening for referral
Catherine Goodman
Teresa Snyder

Chapter
Screening for Chest, Breasts and
17 Ribs

DR FA T I M A A M J A D P T
CAUSES OF CHEST, RIB&
BREAST PAIN
SYSTEMIC CAUSES

CANCER

CARDIAC

NMS CAUSES GIT

NERVE
PULMONARY
MUSCLE
OTHER
JOINT
Screening Model
Cardiac
Chest
or non
pain
cardiac

• Past medical history

• Risk factor
• Clinical presentation
• Associated symptoms
SCREENING FOR ONCOLOGICAL
CAUSES OF CHEST PAIN
• Primary chest, neck, shoul­der, and/or upper back pain
• Primary tumor=referred pain to breast
• Secondary tumor(metastasized)=pulmonary symptoms
• Previous history=red flag
CLINICAL
PRESENTATIONS(METASTASES TO
LUNG)
Pleural pain, dyspnea, and persistent cough
symptoms may not occur until the neoplasm is quite large or invasive because the lining
surrounding the lungs has no pain percep­tion.
tumor is large enough to press on other nearby structures or against the chest wall
SKIN CHANGES
Metastatic carcinoma can present with a cellulitic appearance on the anterior chest wall
skin lesion may be flat or raised and any color from brown to red or purple.
telangiectasis, a perma­nently dilated group of superficial capillaries or venules
Skin infection
Lymph node changes
PALPABLE MASS
palpate a painless sternal or chest wall mass
Sensory changes
When lesion extend to chest wall and involve the nerve root then pain is primary feature
Pain is more diffuse and radiate
Irritation of intercostal nerve= unilateral burning sensations
Sensory loss
Hyperesthesia
Dermatome pattern
SCREENING FOR CARDIOVASCULAR CAUSES
OF
CHEST, BREAST, OR RIB PAIN
Risk Factor
Clinical presentation
SCREENING FOR PLEUROPULMONARY
CAUSES OF
CHEST, BREAST, OR RIB PAIN
Obstruction, restriction, dilation, or distention of the large airways
Pulmonary artery
Past Medical History:
◦ Pulmonary infection
◦ Recent hospitalization
◦ Risk factor for pulmonary diseases
CLINICAL PRESENTATIONS
Tracheobronchial pain is referred to the anterior neck or chest at the same levels as the points
of irritation in the air passages.
Pleuritic pain=worsens with coughing, deep breathing, other respiratory movements or motion
of the chest wall, relieved with splinting
Red flags=Symptoms that increase with deep breathing and activity or the presence of a
productive cough with bloody or rust-colored sputum
Symptoms relieved by sitting up are indicative of pulmonary impraiment
SCREENING FOR
GASTROINTESTINAL CAUSES OF
CHEST, BREAST, OR RIB PAIN
epi­gastric or upper GI conditions
GERD ("heartburn"or esonhaeitis)
Past medical history:
alcoholism, cirrhosis, esophageal varices, and esophageal cancer or peptic ulcers
Long-term use of NSAIDs=peptic ulcer
Chronic alcohol use= cirrhosis of lever
Clinical presentation
Upper GI and pancreatic problems=referred pain to posteriorly to upper back (inter scapular and
sub scapular regions)
Esophagus problems
Esophageal dysfunction will present with symp­toms such as anterior neck and/or anterior chest
pain
pain during swallowing (odynophagia)
dif­ficulty swallowing (dysphagia) at the level of the lesion
upper esophagus may cause pain in the (anterior) neck
lower esophagus= xiphoid process, radiating around the thorax to the middle of the back
Differentiate from thoracic disc disease
Bowel and bladder changes in disk disease
Epigastric pain
sub­sternal or upper abdominal (just below the xiphoid process) discomfort
radiation posteriorly to the back
Gastric duodenal peptic ulcer=lower chest rather than in the upper abdomen
Peptic ulcer pain = relieved by antacid and food, not produced by effort and lasts longer than
angina
GERD
gripping, squeezing, or burning, described as
"heartburn" or "indigestion.“
Like that of angina pectoris, the discomfort of reflux esophagitis may be precipitated by
recumbency or by meals; however, unlike angina, it is not precipitated by exercise and is relieved
by antacids
Hepatic and pancreas
liver, gallbladder, common bile duct, and pancreas=with referral of pain to the interscapular,
subscapular, or middle/low back regions
Hepatic disorders may cause chest pain with radiation of pain to the shoulders and back
Chole­cystitis = epigastric or right upper quadrant pain
associated with nausea, vomiting, and fever and chills
dark urine and jaundice indicate that a stone has obstructed the common duct
Tenderness to palpation in the right upper quadrant
gallbladder problem can result in a sore tenth rib tip (right side anteriorly)
Acute pancreatitis causes pain in the upper part of the abdomen that radiates to the back (usually
anywhere from T10 to L2)
SCREENING FOR BREAST
CONDITIONS THAT CAUSE CHEST
OR BREAST PAIN
breast conditions =breast pain or neck, shoulder or upper back pain
The changes in integument, breast, or surrounding soft tissues.
discharge from the nipple
Past Medical History:
A past history of breast cancer, heart disease, recent birth, recent upper respiratory infection(URI),
overuse, or trauma (including assault)
personal history of previ­ous breast surgeries, including mastectomy, breast reconstruction or
breast implantation or augmen­tation
family history of breast cancer
chemotherapy or radiation therapy
Clinical presentations
Cyclic breast pain=hormone fluctuation, get worse during perimenopause
SCREENING FOR
MUSCULOSKELETAL CAUSES OF
CHEST, BREAST, OR RIB PAIN
Tietze's syndrome Dorsal nerve root irritation
Costochondritis Thoracic outlet syndrome
Hypersensitive xiphoid, xiphodynia Thoracic disc disease
Slipping rib syndrome Postoperative pain
Trigger points Breast
Myalgia Mastodynia
Rib fracture, costochondral dislocations Trigger points
Cervical spine disorders, arthritis Trauma (including motor vehicle accident, assault)
Neurologic
Nerve root, intercostal neuritis
Costochondritis
Inflammation of costal cartilage with out swelling
Risk factors: more common in female, after 40, 2nd, 3rd, 4th, 5th costochonderal joints
sharp pain along the front edges of the sternum, especially on the left side
Differ from MI , pain is not in the center of chest, it is along the edges
Tietze's Syndrome
Inflammation of ribs and its costal cartilages
Anterior chest pain
Painful swelling of one or more costochondral
articulations
Hypersensitive Xiphoid
The hypersensitive xiphoid (xiphodynia) is tender to palpation, and local pressure may cause
nausea and vomiting. This syndrome is manifested as epigastric pain, nausea, and vomiting.
Slipping Rib Syndrome
The slipping, or painful, rib syndrome (sometimes also referred to as the clicking rib syndrome)
Hypermobility of lower ribs
inadequacy or rupture of the interchondral fibrous attachments
Trigger Points
most common musculoskeletal cause of chest pain is TrPs, sometimes referred to as myofascial
trigger points (MTrPs)
TrPs accom­panied by symptoms such as vertigo, headache, visual changes, nausea, and syncope
are yellow flags warning of autonomic involvement
Acute MI may activate TrPs in pec.major
Myalgia
muscular pain, can cause chest pain separate from TrP pain but with a similar etiologic basis of
prolonged or repeated movement
well localized seen on Palpation
Contraction
Stretch
With true myalgia , squeezing the muscle belly will reproduce painful chest symptoms
Cervical Spine Disorders
Cervicodorsal arthritis=sharp and piercing but may be described as a deep, boring, dull
discomfort
With flexion or hyperextension of the upper spine
Rest may not alleviate the symptoms, and prolonged recumbency makes the pain worse
Discogenic disease can also cause referred pain to the chest
SCREENING FOR NEUROMUSCULAR OR
NEUROLOGIC CAUSES OF CHEST, BREAST, OR
RIB PAIN
Intercostal Neuritis
Dorsal Nerve Root Irritation
Thoracic Outlet Syndrome
Thoracic Outlet Syndrome
Thoracic outlet syndrome (TOS) refers to compression of the neural and/or vascular structures
that leave or pass over the superior rim of the thoracic cage
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