Background
The patient is 36 years old. Single. Previously healthy. Smokes and works at a fish processing plant. A day ago, the patient lifted something heavy at work.
The patient experienced acute pain (VAS 7) between the shoulder blades and now has pain (VAS 5) radiating forward into the right side of the chest, especially during deep inhalation and coughing.
Consultation video
Medical history
- Doctor
What can I help you with?
- Patient
I suddenly got very bad pain between my shoulder blades yesterday at work.
- Doctor
What happened when it started?
- Patient
I lifted something heavy… and then it happened suddenly.
- Doctor
Where do you feel the pain now?
- Patient
Mostly between the shoulder blades… but it also radiates to the chest on the right side.
- Doctor
How is the pain now compared to when it started?
- Patient
It was worse at first, then it was really intense. Now it's still painful, but not quite as bad.
- Doctor
Is there anything that makes it worse?
- Patient
Yes, when taking a deep breath… and when coughing.
- Doctor
Does it get worse when you move your back?
- Patient
Yes, especially if I twist.
- Doctor
Have you experienced tingling, numbness, or weakness?
- Patient
No, not like that. It's mostly pain.
Standard examination
Perform standard examination:
- 1 Inspection
- 2 Active movements
- 3 Passive movements
- 4 Isometric movements
- 5 Palpation
Tentative diagnosis
based on medical history and standard examination- Pain from thoracic disc problems.
- Differential diagnoses are myalgia in thoracic back extensors and in scapular muscles.
Examination
Special tests to strengthen or weaken the likelihood of the tentative diagnosis.
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1. Respiration and observation
Doctor
I am looking a bit at how you breathe. Can you take a deep breath in?
Patient
Attempts to take a deep breath, but pauses slightly with pain reaction, grimace, and defensive body language.
Yes, I feel it there.
It goes from the back and forward into the chest.
Findings
- Pain from the back and forward into the chest, especially on the right side during deep inspiration.
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2. Active rotation of the thoracic spine
Doctor
Can you rotate your upper body to the right?
Patient
Rotates carefully, but is stopped by pain before full movement.
Yes, it is the same pain.
It goes from the back forward.
Findings
- Pain with active rotation to the right, with the same radiation forward into the chest.
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3. Passive rotation to the right
Doctor
I assist with rotating the upper body passively.
Patient
Reacts clearly when the movement provokes the recognizable pain.
Yes, right there.
It radiates on the right side.
Findings
- Pain also with passive rotation to the right.
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4. Strength testing of the back muscles
Doctor
I will test the strength a bit. Try to resist.
Patient
Passes the test without obvious weakness. The patient is a bit cautious due to pain, but not weak.
It's okay, but it's a bit uncomfortable.
Findings
- Normal strength when testing the back muscles.
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5. Examination in prone position
Doctor
Lie on your stomach, then I will feel your back.
Patient
Lies down carefully and stiffly on the bench. Pressure on the thoracic spine between the shoulder blades reproduces the pain, which radiates to the chest.
There, yes, it goes to the chest.
Findings
- Pain in the thoracic spine that radiates to the chest when the doctor presses on the back between the shoulder blades.
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6. Palpation of paraspinal and scapular musculature
Doctor
Palpates the back extensors and muscles around the right scapula.
Patient
Clear local tenderness, more tenderness than sharp nerve pain.
Yes, it is tender there too.
Findings
- Tenderness on palpation of the back extensors.
- Tenderness in the muscles around the right scapula.
Learning points
- 1 Thoracic pain distribution can be experienced near the chest.
- 2 It is important to examine both movement, palpation, and respiratory dependence.
- 3 Differentiate between thoracic disc problems, muscular pain in the thoracic extensors, and scapular myalgia.