ok Screening the Chest, Breast and Ribs.pptx

SCREENING THE CHEST, BREAST AND RIBS Anisa THE SCREENING MODEL TO EVALUATE THE CHEST, BREAST OR RIBS Chest pain can be evaluated in one of the two ways: o Cardiac versus non cardiac o Systemic vs NMS Paying attention to past medical history, Woman w...

SCREENING THE CHEST, BREAST AND RIBS Anisa THE SCREENING MODEL TO EVALUATE THE CHEST, BREAST OR RIBS Chest pain can be evaluated in one of the two ways: o Cardiac versus non cardiac o Systemic vs NMS Paying attention to past medical history, Woman with chest, breast, axillary or shoulder pain of unknown origin at presentation must be questioned regarding breast self examination. Lumps and nodules must be examined by physician. PAST MEDICAL HISTORY Helps the therapist to further differentiate between the conditions. RISK FACTORS Risk for cardiac caused symptoms increases with o advancing age o Tobacco use o Menopause (women) o Family history of HTN, CAD & high cholesterol Risk factors associated with non cardiac condition vary with each individual condition (infectious, rheumatologic, pulmonary or other systemic causes).  CLINICAL PRESENTATION Pain assessment and associated symptoms Physical assessment Assess vital signs Auscultation provide cardiopulmonary clues Spinal referred pain are chest pain produced during movement(resistive)  CLINICAL PRESENTATION For example, pain that is positional or reproduced by palpation is not as suspicious as pain that radiates to one or both shoulders or arms or that is precipitated by exertion. Physicians agree that the chest pain history by itself is not enough to rule out cardiac or other systemic origin of symptoms. In most cases, some diagnostic testing is needed. Chest pain associated with increased activity is a red flag for possible cardiovascular involvement. In such cases, the onset of pain is not immediate but rather occurs 5 to 10 minutes after activity begins. This is referred to as the "lag time" and is a screening clue used by the physical therapist to assess when chest pain may be caused by musculoskeletal dysfunction (immediate chest pain occurs with use) or by possible vascular compromise (chest pain occurs 5 to 10 minutes after activity begins).  ASSOCIATED SIGNS AND SYMPTOMS If underlying infectious or inflammatory process causes pain or symptoms there may be change in vital signs and constitutional symptoms. Non cardiac causes vary according to system involved. For example, cough, sputum production, and a recent history of upper respiratory infection may point to a pleuropulmonary origin of chest or breast pain. Anyone with persistent coughing or asthma can experience chest pain related to the strain of the chest wall muscles. Chest or breast pain associated with GI disease is often food related in the presence of a history of peptic ulcer, gastroesophageal reflux disease (GERD), or gallbladder problems. Blood in the stool or vomitus, along with a history of chronic nonsteroidal antinflammatory drug (NSAID) use, may point to a GI problem. SCREENING FOR ONCOLOGIC CAUSES OF CHEST OR RIB PAIN Primary cancer affecting the chest with referred pain to the breast is not as common as cancer metastasized to the pulmonary system with subsequent pulmonary and chest/ breast symptoms. CLINICAL PRESENTATION: Symptoms associated with metastasis to pulmonary system are Pleural pain Dyspnea Persistent cough If the visceral system involved, Symptoms may not occur until neoplasm is large or invasive because lining surrounding the lung has no pain perception. Changes in skin, lesion or masses should be documented  SKIN CHANGES Metastatic carcinoma can present with a cellulitic appearance on anterior chest wall. Skin lesion may be flat or raised and any color from brown to red or purple. Liver impairment from cancer or any liver disease causes skin changes such as angioma Spider angioma (spider nevus) is form of telangiectasis a permanently dilated group of superficial capillaries (or venules).  SKIN CHANGES In the presence of skin lesions, ask about a recent history of infection of any kind, use of prescription drugs within the last 6 weeks, and previous history of cancer of any kind. Look for lymph node changes. Report all of these findings to the physician.  PALPABLE MASS Therapist may palpate a painless sternal or chest wall mass when evaluating head & neck region. Primary tumor is usually a lymphoma, multiple myeloma or carcinoma of the breast, kidney or thyroid. When involvement of the chest wall and nerve roots results in pain, the pattern is more diffuse, with radiation of pain to the affected nerve roots. CASE Referral: A 53-year-old university professor came to the physical therapy clinic with complaints of severe left shoulder pain radiating across her chest and down her arm. She rated the pain a 10 on the NRS Past Medical History: She had a significant personal and social history, including ovarian cancer 10 years ago, death of a parent last year, filing for personal bankruptcy this year, and a divorce after 30 years of marriage. Clinical Presentation: First Visit: During the screening examination for vital shows: BP: 220/125 mm Hg. Pulse: 88 beats/minute. Pulse oximeter measured 98%. Oral temperature: 98.0°F. She denied any previous history of cardiovascular problems or current feelings of stress. CLINICAL PRESENTATION: SECOND VISIT The therapist was able to reproduce the symptoms described above with moderate palpation of the eighth rib and side bending motion to the left side. The client described the symptoms as constant, sharp, burning, and intense. She had pain at night if she slept too long on either side. Side lying on the involved side and slump sitting did not reproduce the symptoms. WHAT SHOULD THERAPIST DO?  Cardiac-related chest pain may arise secondary to angina, myocardial infarction, pericarditis, endocarditis, mitral valve prolapse, or aortic aneurysm. There is no single element of chest pain history powerful enough to predict who is or who is not having a coronary-related incident. Medical referral is advised whenever there is any doubt; medical diagnostic testing is almost always required. Cardiac-related chest pain also can occur when there is normal coronary circulation, as in the case of clients with pernicious anemia. Affected clients may have chest pain or angina on physical exertion because of the lack of nutrition to the myocardium. SCREENING FOR CARDIOVASCULAR CAUSES OF CHEST, BREAST OR RIB PAIN Risk Factors Gender age Cardiac Pain Patterns Presence of any or all of these Ps suggests no MI: Pleuritic pain Pain on palpation Pain with changes in position SCREENING FOR CARDIOVASCULAR CAUSES OF CHEST, BREAST OR RIB PAIN  STABLE ANGINA Episodes of stable angina usually develop slowly and last 2 to 5 minutes. Discomfort may radiate to the neck, shoulders, or back. Shortness of breath is common. Symptoms of angina may be similar to the pattern associated with a heart attack. One primary difference is duration. Angina lasts a limited time (a few minutes up to a half hour) and can be relieved by rest or nitroglycerin.  UNSTABLE ANGINA A sudden change in the client's typical anginal pain pattern suggests unstable angina. Pain that occurs without exertion, lasts longer than 10 minutes, or is not relieved by rest or nitroglycerin signals a higher risk for a heart attack. Immediate medical referral is required under these circumstances.  SCREENING FOR PLEUROPULMONARY CAUSES OF CHEST, BREAST OR RIB PAIN Pulmonary chest pain usually results from obstruction, restriction, dilation of the large airways or large pulmonary artery walls Past Medical History: History of cancer Pulmonary infection Accident or hospitalization Age Smoking Eating disorders (or malnutrition from some other cause). Immune system suppression CLINICAL PRESENTATION Chest pain tends to be sharply localized worsens with coughing deep breathing respiratory movements or motion of chest wall relieved by maneuvers that limit the expansion of a particular part of the chest is likely to be pleuritic in origin. change in breathing pattern , SOB  SCREENING FOR GASTROINTESTINAL CAUSES OF CHEST, BREAST OR RIB PAIN GI causes of upper thorax pain are a result of epigastric or upper GI conditions. Past Medical History Alcoholism cirrhosis esophageal varices esophageal cancer peptic ulcers  ESOPHAGUS Esophageal dysfunction will present with symptoms Early satiety + weight loss => esophageal carcinoma pain in the (anterior) neck=>Lesions of the upper esophagus pain in xiphoid process, radiating around thorax to mid back => lower esophagus disc disease: there may be bowel or bladder changes & sometimes numbness and tingling in upper extremities Epigastric Pain Epigastric pain is typically characterized by substernal or upper abdominal (just below the xiphoid process) discomfort Antacid and food often immediately relieve pain caused by an ulcer. Hepatic and Pancreatic Systems disorders of the liver, gallbladder, common bile duct, and pancreas, with referral of pain to the interscapular, subscapular or middle/low back region This type of pain pattern can be mistaken for angina pectoris or myocardial infarction  CASE Referral: A 33-year-old woman in her 29th week of gestation with her first pregnancy was referred to a physical therapist by her gynecologist due to chest pain. Her abdominal sonogram and lab tests were normal. A chest x-ray was read as negative. Past Medical History: None. The client had the usual childhood illnesses but had never broken bones and denied use of tobacco, alcohol etc. No recent history of infections, viruses, coughs, trauma or accidents & changes in GI function and no history of cancer. Clinical Presentation: Although there were no signs and symptom associated with the respiratory system. Palpation of the upper chest, thorax, and ribs revealed pain on palpation of the right tenth rib (anterior). The client had no red flags.  Knowing that transient osteoporosis can be associated with pregnancy, the therapist gave the client the Osteoporosis Screening Evaluation. The client replied "yes" to three questions (Caucasian or Asian, mother diagnosed with osteoporosis, physically inactive). What is the provisional diagnosis? What will be the investigating methods? What will be the treatment protocol? SCREENING FOR BREAST CONDITIONS THAT CAUSE CHEST OR BREAST PAIN present with breast pain as the primary complaint, but description is of shoulder, arm, neck or upper back pain Past Medical History breast cancer heart disease recent upper respiratory infection (URI) Trauma Surgeries: mastectomy, breast reconstruction CLINICAL SIGNS AND SYMPTOMS Family history Palpable breast nodules or lumps May be painless Breast pain with possible radiation to inner aspect of arm Skin surface over a tumor may be red, warm, edematous, firm, and painful. Firm, painful site under the skin surface Skin dimpling Unusual nipple discharge or bleeding Pain aggravated by jarring or movement of the breasts Pain that is not aggravated by resistance to isometric movement of the upper extremities CAUSES Mastodynia: Irritation of upper dorsal intercostal nerve causes chest pain associated with ovulatory cycles. Mastitis: Inflammatory condition associated with lactation. Mammary duct obstruction causes clogged duct. Breast becomes red, swollen and painful even warm and hot. Risk factors: cracked, bleeding, painful nipples, stressor fatigue BENIGN TUMORS AND CYSTS Once they lumped together and called fibrocystic breast disease Benign: unchanged lump of long duration intraductal papilloma: wart like growth inside the breast fat necrosis: fat breaks down and clumps together mammary duct ectasia : ducts near the nipple become thin-walled and accumulate secretions PAGET'S DISEASE rare form of ductal carcinoma affecting the nipple. It is characterized by a red (scaly) rash, itching, or bleeding on the breast that often surrounds the nipple and areola Symptoms are unilateral, and the breast may be sore, itch, or burn. Diagnosis is often delayed because the symptoms seem harmless or the condition is misdiagnosed as dermatitis BREAST CANCER Clinical presentation: Breast mass Retraction (DIMPLING) Edema Axillary mass Scaly nipple Tender breast  SCREENING FOR OTHER CONDITIONS AS A CAUSE OF CHEST, BREAST, OR RIB PAIN Breast Implants Scar tissue or fibrosis from a previous breast surgery Past Medical History: reduction mammoplasty, mastectomy Anxiety Dull, aching discomfort in the substernal region and in the anterior chest Sinus tachycardia Fatigue , dyspnea Diaphoresis Choking sensation Hyperventilation, numbness and tingling of hands and lips Cocaine  ANABOLIC-ANDROGENIC STEROIDS CLINICAL SIGNS AND SYMPTOMS Chest pain Elevated blood pressure Ventricular tachycardia Weight gain Peripheral edema Jaundice (chronic use) Acne on the face, upper back, chest Altered body composition Development of male pattern baldness Gynecomastia Personality changes called "steroid psychosis" Females: secondary male characteristic SCREENING FOR MUSCULOSKELETAL CAUSES OF CHEST, BREAST, OR RIB PAIN Costochondritis Characterized by sharp pain along the front edges of the sternum Tietze syndrome Inflammation of rib and its cartilage Upper anterior chest pain Tenderness of costochondral joints Bulbous swelling of costal cartilage  CASE Referral: A 53-year-old woman was referred by her physician with a diagnosis of left anterior chest pain. The woman is employed at a sawmill and performs tasks that require repetitive shoulder flexion and extension Past Medical History: hysterectomy 10 years ago , smoker for 30 years Clinical Presentation: Pain Pattern: The woman described the onset of her pain as sudden, crushing chest pain radiating down the left arm, occurring for the first time 6 weeks ago. In ER, tests were negative for cardiac incident and released with a diagnosis of "stress-induced chest pain." client experienced the same type of episode of chest pain 10 days ago. Today, her symptoms include extreme tenderness and pain. She relates that because of divorce proceedings and child custody hearings, she is under extreme stress at this time.  What will be the examination protocols followed by therapist? What is the provisional diagnosis? Is the treatment is indicated based on diagnosis? 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 (clicking rib syndrome) occurs when hypermobility of the lower ribs. Pain worse by slump sitting or side bending to the affected side. This condition can occur alone or can be associated with a broader phenomenon such as myofascial pain syndrome.  TRIGGER POINTS most common musculoskeletal cause of chest pain is TrPs Past Medical History upper respiratory infection Immobility muscle strain Clinical Presentation On examination??? Myalgia Myalgia or muscular pain cause chest pain basis of prolonged or repeated movement Rib fracture Periosteal pain associated with fractured ribs can cause sharp, localized pain increase in symptoms with trunk motions and respiratory movements Cervical Spine Disorders Cervicodorsal arthritis may produce chest pain similar to that of angina pectoris Discogenic disease can also cause referred pain to the chest  SCREENING FOR NEUROMUSCULAR OR NEUROLOGIC CAUSES OF CHEST, BREAST, OR RIB PAIN Intercostal neuritis such as herpes zoster or shingles produced by a viral infection of a dorsal nerve root, can cause neuritic chest wall pain, which can be differentiated from coronary pain Dorsal Nerve Root Irritation Dorsal nerve root irritation of the thoracic spine is another neuritic condition that can refer pain to the chest wall Thoracic Outlet Syndrome refers to compression of the neural or vascular structures that leave or pass over the superior rim of the thoracic cage  GUIDELINES FOR PHYSICIAN REFERRAL No change is noted in uneven blood pressure from one arm to the other after intervention for a vascular TOS component. The therapist who suspects a client may be using anabolic steroids should report findings to the physician or coach if one is involved. Symptoms are unrelieved or unchanged by physical therapy intervention. Medical referral is advised before initiating treatment for anyone with a past history of cancer presenting with symptoms of unknown cause, especially without an identifiable movement system impairment. THANK YOU!