Case

A 51 year old patient comes into your clinic complaining of mild chest pain. The patient describes that the mild pain is worse when inhaling deeply and when twisting their torso. A CT scan shows no evidence of fractures. On physical examination the space between the patient’s 5th and 6th ribs on the right anterolateral side is also sore to the touch. The patient notices that whenever they breath there is bulging or depression between those ribs.

Question 1/2 - What do you think has occurred?

Click on your selected option(s) below  (correct = 1, over-thinking = 2+)

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Incorrect. While bleeding could yield mild discomfort, the diagnosis does not explain the bulging/depression observation with respiration.   

Incorrect. Diaphragmatic rupture would be very painful and changes to the movement of the diaphragm with injury are not palpable on the thoracic wall and would not explain the bulging/depression observation with respiration.   

Incorrect. The patient history indicates that a CT shows no evidence of fractures, a fracture undetectable by CT is unlikely to yield any problems.

Correct! The bulge at the 5th intercostal space indicates a weakness in the ability of the intercostal musculature to maintain the taut space between the ribs, resulting in a bulge/depression during respiration.

Incorrect. While a small fracture could yield mild discomfort, the diagnosis does not explain the bulging/depression observation with respiration.   

Incorrect. An aneurism can lead to mild discomfort in the mediastinum with a slight leak of blood (which irritates surrounding tissues), the diagnosis does not explain the bulging/depression observation with respiration.