What is the initial workup for a patient presenting with xiphoidinia (inflammation of the xiphoid process)?

Initial Workup for Xiphoidinia (Xiphoid Process Inflammation)

The initial workup for xiphoidinia should include a focused physical examination with palpation of the xiphoid process to reproduce the pain, followed by chest radiography and/or CT imaging to evaluate the xiphoid process structure and rule out other pathologies.

Diagnostic Approach

Physical Examination

• Palpation of the xiphoid process: The most important diagnostic step is direct palpation of the xiphoid process to reproduce the patient's pain 1, 2
• Look for:
  • Tenderness directly over the xiphoid process
  • Hard mass or swelling in the epigastric region
  • Pain that radiates to chest, abdomen, throat, or arms when the xiphoid is palpated
  • Abnormal xiphoid morphology (enlarged, hooked, or "tack hammer" deformity)

Imaging Studies

• Chest radiography: Initial imaging to visualize xiphoid process morphology and rule out other thoracic pathologies 3
• CT scan with contrast: Recommended when more detailed evaluation is needed 3, 4
  • Provides better visualization of the xiphoid process structure
  • Rules out other thoracic and abdominal pathologies
  • Can identify abnormal xiphoid morphology (enlarged, deformed)

Laboratory Testing

• Complete blood count
• Basic metabolic panel
• Inflammatory markers (ESR, CRP) to assess for inflammatory processes

Differential Diagnosis Evaluation

Xiphoidinia frequently mimics other serious conditions, requiring careful exclusion of:

1. Cardiac pathology:

   • ECG to rule out acute coronary syndrome 5
   • Cardiac enzymes if cardiac etiology suspected

2. Gastrointestinal disorders:

   • Consider evaluation for GERD, which can be a risk factor for secondary xiphoidalgia 1
   • Gallbladder disease assessment if right upper quadrant pain is present

3. Musculoskeletal conditions:

   • Costochondritis
   • Sternoclavicular joint dysfunction

Special Considerations

• Occupational history: Essential to obtain as repeated microtrauma can cause xiphoid syndrome 6
• Previous abdominal surgeries: May contribute to xiphoid process irritation
• Comorbidities: Assess for conditions that may exacerbate symptoms (GERD, coronary artery disease) 1

Common Pitfalls

• Misdiagnosis as cardiac or gastrointestinal disease is common, leading to unnecessary testing and delayed treatment 5
• Failure to perform careful palpation of the xiphoid process during physical examination
• Overlooking occupational factors that may contribute to xiphoidinia 6

Algorithm for Workup

1. Perform focused physical examination with direct palpation of xiphoid process
2. If pain is reproduced with palpation, obtain chest radiography
3. If radiography is inconclusive or abnormal, proceed to CT imaging
4. Rule out cardiac causes with ECG and cardiac enzymes if clinically indicated
5. Evaluate for gastrointestinal disorders if symptoms suggest this etiology
6. Consider occupational factors and history of trauma to the chest wall

Remember that xiphoidinia is often a diagnosis of exclusion after ruling out more serious conditions, but the hallmark finding is reproduction of the patient's pain with direct palpation of the xiphoid process.