A 25-year-old woman comes to the office due to "chest pain" that began 2 days ago. The pain is described as a constant soreness across the chest, and the patient is unable to sleep prone because of the pain. She is an avid runner and kickboxer and has been unable to maintain her normal exercise routine due to discomfort wearing a sports bra. The patient is sexually active with her husband and recently stopped taking oral contraceptives because the couple are trying to have a child. Her last menstrual period was 3 weeks ago; menses are regular, occur approximately every 28 days, and last for 6 days. The patient takes a daily folic acid supplement and no other medications. Vitals signs are normal. Palpation demonstrates bilateral, nonfocal chest tenderness and diffusely nodular, dense breasts. Which of the following is the most likely diagnosis in this patient?

Question

A 25-year-old woman comes to the office due to "chest pain" that began 2 days ago.  The pain is described as a constant soreness across the chest, and the patient is unable to sleep prone because of the pain.  She is an avid runner and kickboxer and has been unable to maintain her normal exercise routine due to discomfort wearing a sports bra.  The patient is sexually active with her husband and recently stopped taking oral contraceptives because the couple are trying to have a child.  Her last menstrual period was 3 weeks ago; menses are regular, occur approximately every 28 days, and last for 6 days.  The patient takes a daily folic acid supplement and no other medications.  Vitals signs are normal.  Palpation demonstrates bilateral, nonfocal chest tenderness and diffusely nodular, dense breasts.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d0ca_0515_bc81_bf25a0d3d9e7_MD0003_00 In women, the breasts are a common source of bilateral, nonfocal chest pain because breast tissue is heterogeneous (ie, composed of glands, stroma, and ducts), and pain can occur with normal tissue proliferation. Breast tissue proliferation varies with hormonal fluctuations (eg, estrogen, progesterone) during the menstrual cycle. In some women (typically premenopausal and of reproductive age), glandular tissue proliferation can lead to diffusely nodular breasts and breast pain known as fibrocystic changes of the breast. Patients with fibrocystic breast changes typically have cyclic, premenstrual breast tenderness (as in this patient) and improvement in pain symptoms during or after menstruation. On examination, both breasts typically have multiple nodulocystic masses. Because fibrocystic changes are benign, patients can be reassured and offered symptomatic relief with nonsteroidal anti-inflammatory drugs and/or oral contraceptives. (Choice A) Costochondritis is inflammation of the rib cartilage, which can cause parasternal chest pain that worsens with chest movement (eg, coughing, deep inhalation). In contrast to this patient's bilateral, nonfocal pain, costochondritis is characterized by pain that is typically unilateral, sharp or pressure-like, and associated with focal tenderness to palpation of the chest wall. It is not associated with diffuse breast nodularity. (Choice B) Cyclic mastalgia is a benign breast disorder diagnosed in women with breast pain related to the menstrual cycle (ie, due to fluctuations in estrogen and progesterone). Although patients also have bilateral, premenstrual breast tenderness, they have no associated breast nodularity or masses. (Choice C) Fat necrosis of the breast is an uncommon complication of breast trauma (typically invasive breast surgery) and presents as a unilateral, firm, irregular mass. In contrast, this patient has bilateral breast nodularity. (Choice D) Although fibroadenomas are also estrogen sensitive and vary in size and tenderness depending on the menstrual cycle, they typically present as a solitary, unilateral, well-circumscribed, and mobile breast mass. (Choice F) A phyllodes tumor is a rare, rapidly growing breast tumor that presents as a unilateral, smooth, firm, and painless breast mass of variable size. Educational objective: Fibrocystic breast changes are a common cause of cyclic, premenstrual breast tenderness in women of reproductive age. Patients typically have diffusely nodular breasts and bilateral, nonfocal breast or chest pain. References: The role of E2/P ratio in the etiology of fibrocystic breast disease, mastalgia and mastodynia. (http://www.ncbi.nlm.nih.gov/pubmed/31168213)

A 25-Year-Old Woman Comes to the Office Due to "Chest