Review Question - QID 220661

This patient who presents with pleuritic chest pain that can be reproduced upon palpation most likely has costochondritis. This condition is caused by musculoskeletal inflammation.

Costochondritis is caused by inflammation of the connection between the rib body and the costal cartilage. It presents with chest pain that can be pleuritic in nature and is typically reproducible on physical exam. In the absence of other concerning findings such as abnormal vitals indicating tachycardia and tachypnea, the diagnosis can be made on clinical suspicion alone. Additional workup can be considered if patients have risk factors for myocardial infarction or pulmonary embolism such as a long flight, stasis, malignancy, estrogen use, or recent surgery. Treatment of costochondritis is with physical therapy and non-steroidal anti-inflammatory drugs.

Schumann et al. review the evidence regarding the diagnosis and treatment of costochondritis. They discuss how this disease presents with chest pain. They recommend differentiating this disease from other causes of chest pain.

Figure/Illustration A is a chest radiograph with a normal mediastinal contour (red circle) and without other significant findings. This appearance is consistent with costochondritis.

Incorrect Answers:
Answer 1: Clot in the pulmonary arteries describes a pulmonary embolism that could present with chest pain and shortness of breath but would also likely present with abnormal vital signs (such as hypoxia and tachypnea) and would occur in the setting of risk factors.

Answer 2: A clot in the pulmonary veins is an unlikely diagnosis since a dislodged clot would lodge in the pulmonary arteries and not pass through the capillaries.

Answer 3: Ischemia of the myocardium represents a myocardial infarction which would be unlikely in a patient who is otherwise young and healthy. Patients can have an infarction or angina with the use of recreational drugs but this typically occurs immediately after use and the pain is not reproduced with manual palpation.

Answer 5: Psychogenic etiology is a diagnosis of exclusion for patients with somatic symptom disorder. This diagnosis should only be made after organic etiologies are ruled out.

Bullet Summary:
Costochondritis presents with chest pain that can be pleuritic, reproduced with palpation, and is worsened with stretching of the chest wall.