A 42-year-old woman comes to the emergency department for evaluation of chest pain. She was moving furniture in her summer house 2 days ago when she experienced sharp pain in the left side of the sternum that quickly subsided. Since then, the patient has had episodic pain with deep inspiration or trunk movement. She has no fever or cough. The patient has a history of hypertension. Her father died of myocardial infarction at age 67. She does not use tobacco or illicit drugs. Blood pressure is 146/85 mm Hg in the right arm and 142/80 mm Hg in the left arm, pulse is 86/min, and respirations are 12/min. She has localized tenderness to palpation at the left sternal border. Lungs are clear to auscultation, and cardiac examination reveals normal heart sounds without gallops or murmurs. The abdomen is soft and nontender. There is no peripheral edema. Which of the following is the most likely cause of this patient's symptoms?
Differential diagnosis & features of chest pain | |
Coronary artery |
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Pulmonary/pleuritic |
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Aortic |
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Esophageal |
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Chest wall/ |
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PE = pulmonary embolism. | |
This patient's chest pain is most likely due to costosternal syndrome (also known as costochondritis or anterior chest wall syndrome) involving the regional chest wall. It usually occurs after repetitive activity and involves the upper costal cartilage at the costochondral or costosternal junctions. The pain is typically reproduced with palpation and worsened with movement or changes in position (eg, horizontal arm flexion). Patients typically do not have palpable warmth, swelling, or erythema.
(Choices A, G, and I) Conditions causing inflammation of the pleura or pericardium can cause sharp pain worsened with inspiration. Pericarditis often follows an upper respiratory viral syndrome. The pain of pericarditis is typically worse when lying flat and relieved by leaning forward. Examination may show a pericardial friction rub. Pulmonary embolism can cause pleural inflammation with chest pain. However, such cases are typically due to large emboli and are associated with significant hypoxia and shortness of breath. Pneumonia usually presents with fever, cough, and shortness of breath. None of these conditions would be associated with focal tenderness of the chest wall.
(Choice B) Aortic dissection causes sudden, tearing chest pain radiating to the back and blood pressure disparity between the arms. This patient's episodic pain makes this less likely. Blood pressure will normally vary mildly between arms; a difference in systolic or diastolic blood pressure <10 mm Hg is not considered significant.
(Choices D and E) Gastroesophageal reflux disease typically causes postprandial or nocturnal burning pain in the upper abdomen and chest. Esophageal spasm can cause chest pain with meals or swallowing.
(Choice F) Panic disorder is usually a diagnosis of exclusion and can present with episodic chest pain, shortness of breath, and palpitations. Patients usually have intense fear/anxiety, and chest wall tenderness is not seen.
(Choice H) Pulmonary arterial hypertension usually presents with exertional dyspnea, lethargy, and fatigue. Other symptoms, such as exertional chest pain, syncope, and peripheral edema, are generally seen in advanced disease.
(Choice J) Unstable angina is characterized by exertional chest pressure, often radiating to the arm or jaw. Local chest tenderness does not rule out a cardiac cause of chest pain but is unusual.
Educational objective:
Costosternal syndrome (costochondritis) usually occurs after repetitive activity and is characterized by pain that is reproducible with palpation and worsened with movement or changes in position.