Doug Montgomery: A 38-Year-Old Male With Anterior Chest Wall Pain Made Worse by Bending

Doug Montgomery

Doug Montgomery is a 36-year-old truck driver with the chief complaint of, “I can’t exercise because my chest is killing me.” Doug stated that ever since he took a hit to the chest during martial arts training, he has been suffering from severe chest wall pain. In spite of Advil, topical analgesic balm, and ice packs, the pain has persisted. He noted that the pain was made worse whenever he bent over or coughed. He went on to say, “I keep getting my days and nights mixed up because every time I roll over, it wakes me up.” He said that he was afraid he would fall asleep while driving and kill himself or somebody else. I asked Doug if he ever had anything like this in the past, and he said, “Not really, just the usual back pain after driving over the road all day.” I asked if he was experiencing any other symptoms associated with the chest pain, such as sweating, palpitations, or pain into the jaw or left arm, and he shook his head no. I asked Doug about any fever, chills, or other constitutional symptoms, such as weight loss or night sweats, and he again shook his head no.

I then asked Doug to point with one finger to show me where it hurt the most. He pointed to the area just above his xiphoid process.

On physical examination, Doug was afebrile. His respirations were 16, his pulse was 66 and regular, and his blood pressure was 112/68. Doug’s head, eyes, ears, nose, throat (HEENT) exam was normal, as was his cardiopulmonary examination. Examination of the thyroid gland was normal and well muscled. His abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness. There was no peripheral edema. His low back examination was unremarkable. Visual inspection of the anterior chest wall revealed visual prominence of the xyphoid process ( Fig. 3.1 ). There was no rubor, ecchymosis, or obvious infection. Palpation of the xiphoid process caused Doug to cry out in pain ( Fig. 3.2 ). A careful neurologic examination of the upper extremities was completely normal. Deep tendon reflexes were normal.

Key Clinical Points—What’s Important and What’s Not