Management of Left-Sided Chest Pain with Musculoskeletal Features in a Pre-Diabetic Patient
This patient's presentation is most consistent with musculoskeletal chest pain (costochondritis) given the reproducible tenderness on palpation, positional variation, and post-traumatic onset, but cardiac evaluation with ECG and troponin is mandatory before confirming this diagnosis, particularly given the pre-diabetic status and atypical features like nocturnal dyspnea. 1
Immediate Diagnostic Workup Required
Cardiac Evaluation (Must Be Completed First)
Obtain a 12-lead ECG immediately to exclude acute coronary syndrome, even though the presentation has musculoskeletal features, because pre-diabetic patients are at higher risk for atypical cardiac presentations 1, 2
Measure cardiac troponin levels as soon as possible to rule out myocardial injury, as this is essential in any patient with chest pain and cardiovascular risk factors 3, 4
The sharp, stabbing quality that worsens with position and is reproducible on palpation argues against cardiac ischemia, but diabetic and pre-diabetic patients commonly present with atypical symptoms including sharp pain and left-sided chest discomfort 1, 5
The positional nature (worse sitting, better lying down) and post-traumatic onset with focal tenderness strongly suggest musculoskeletal etiology, which is typically nonischemic 1
Risk Stratification Considerations
Pre-diabetic status increases cardiovascular risk and the likelihood of atypical presentations of acute coronary syndrome 2, 5
The nocturnal shortness of breath and arm numbness warrant careful evaluation, as dyspnea is a common associated symptom of myocardial ischemia, particularly in patients with diabetes 1
The relationship to eating (worse when full) suggests possible gastroesophageal reflux disease, which has increased prevalence in pre-diabetic and diabetic patients (40% vs general population) 5
Diagnostic Algorithm
If ECG and Troponin Are Normal:
The diagnosis of musculoskeletal chest pain (costochondritis) is supported by the focal tenderness at the left lower rib cage, post-traumatic onset, positional variation, and reproducibility on examination 1
Consider chest radiograph (PA and lateral) to exclude rib fracture from the fall, pneumothorax, or other pulmonary pathology 1, 4
If Any Concerning Features Persist:
The nocturnal dyspnea requires further evaluation if it persists beyond the acute injury period, as this could represent cardiac or pulmonary pathology 1
Given the history of childhood asthma, consider pulmonary function testing if dyspnea continues, though the clear chest examination makes active asthma less likely 1
Management Plan
For Confirmed Musculoskeletal Pain:
NSAIDs are first-line treatment for costochondritis with local heat application and activity modification to avoid aggravating movements 1
Reassure the patient that musculoskeletal chest pain is benign and typically resolves within 2-4 weeks with conservative management 1
Advise avoiding prolonged sitting positions that exacerbate the pain 1
Additional Considerations:
Address the pre-diabetic status with lifestyle modification counseling, as this is a modifiable cardiovascular risk factor requiring intervention 1
The dry, itchy areolar skin noted on breast examination may represent eczema or dermatitis and can be managed with topical emollients or low-potency corticosteroids if bothersome 1
Schedule follow-up in 2-3 weeks to reassess symptoms and ensure resolution of chest pain 1
Red Flags Requiring Immediate Re-evaluation
Worsening or persistent dyspnea, new diaphoresis, radiation of pain to jaw/neck/arms, or syncope would necessitate immediate return to emergency department 1
Any change in pain character from sharp/positional to pressure-like or substernal discomfort should prompt urgent cardiac re-evaluation 1
Development of fever, productive cough, or unilateral decreased breath sounds would suggest alternative diagnoses requiring imaging 1, 4