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NOTE: This case demonstration was developed using the diagnostic process described in Chapter 4 and demonstrated in Chapter 5. The reader is encouraged to use this diagnostic process in order to ensure thorough clinical reasoning. If additional elaboration is required on the information presented in this chapter, please consult Chapters 4 and 5.


  • Step 1 Identify the patient's chief concern.

  • Step 2 Identify barriers to communication.

  • Step 3 Identify special concerns.

  • Step 4 Create a symptom timeline and sketch the anatomy (if needed).

  • Step 5 Create a diagnostic hypothesis list considering all possible forms of remote and local pathology that could cause the patient's chief concern.

  • Step 6 Sort the diagnostic hypothesis list by epidemiology and specific case characteristics.

  • Step 7 Ask specific questions to rule specific conditions or pathological categories less likely.

  • Step 8 Re-sort the diagnostic hypothesis list based on the patient's responses to specific questioning.

  • Step 9 Perform tests to differentiate among the remaining diagnostic hypotheses.

  • Step 10 Re-sort the diagnostic hypothesis list based on the patient's responses to specific tests.

  • Step 11 Decide on a diagnostic impression.

  • Step 12 Determine the appropriate patient disposition.

Case Description

OS was a 24-year-old Egyptian female who had been enrolled in a master's degree communications program in the United States for the past 8 months. Her chief concern was left anterior chest pain located immediately lateral to her sternum and distal to the clavicle, deep to her breast tissue at approximately the T3–T5 region. The onset of pain was 12 days prior, while the patient was lying in a semi-reclined position on the couch. She could not recall any specific mechanism of injury or movements she made before the pain began. At the onset of symptoms, the pain was described as sharp with an intensity of 8 to 10 on the 10-point verbal numeric pain scale. At that time, the pain was constant, but was aggravated by sitting in slumped position, inspirations during her breathing cycle, and general movement. She did not experience shortness of breath.

No position of comfort could be found in the supine, side-lying, or prone positions. Easing factors included heat, Advil, sitting up with lumbar and thoracic spine in extended positions, and unloading of left shoulder.

When her symptoms did not change after 3 days, OS visited the Student Health Center. Plain radiographs of the chest obtained by her referring physician were unremarkable and she was referred to physical therapy. Two days later, the pain was significantly decreased and by the morning of the initial physical therapy visit, symptoms at the chest region were only aggravated with palpation or weight bearing through her left upper extremity. Easing factors had not changed. Despite her symptoms, the patient was attending classes.

OS denied a personal history of cardiac disease, respiratory pathology, and cancer. She ...

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