CHEST WALL MASS

CHEST WALL MASS: Excerpt from Differential Diagnosis in Primary Care

The differential diagnosis of this symptom and sign is similar to that of chest pain: Anatomy is the key to both. After visualizing all the organs of the chest and cross-indexing them with the mnemonic MINT, a convenient and extensive differential list can be constructed as in Table 15. The discussion that follows will also concentrate on the most significant of these. The significant lesions of the skin and subcutaneous tissues include sebaceous cysts, cellulitis, neurofibromas, lipomas, and contusions. Unlike the abdomen, the chest seldom is the source of a hernia. In the ribs, look for fractures, contusions, multiple myeloma, and primary and metastatic tumors. In the cartilage, there may be a protruding xiphoid process or a lump at the costochondral junctions in Tietze syndrome. Years ago it was common for empyema, lung abscesses, pleural and pulmonary tuberculosis, and fungi (actinomycosis especially) to work their way out to the skin and form a mass or fistula: This is now unusual. Carcinoma of the lung and mesenthelioma, however, may form a mass on the chest wall by direct extension. In the mediastinal structures, aortic aneurysms used to be a common cause of a pulsating chest wall mass, but they are now rarely seen. Cardiomegaly and pericardial effusions occasionally cause a noticeable protuberance of the precardium but not as frequently as in the past. Tumors of the mediastinum may also cause chest wall masses or protuberances.

Approach to the Diagnosis

The approach to this diagnosis is again a good clinical history and physical examination along with correlation of signs and symptoms. Chest x-ray films with special views and tomography will diagnose most cases, but a biopsy, arteriography, CT scans, and exploratory surgery may be necessary, especially if the lesion turns out to be noninfectious. It is important not to be fooled by a congenital anomaly (e.g., pigeon breast).

Other Useful Tests

1. CBC
2. Radioactive iodine (RAI) uptake and scan (goiter, thyroid neoplasm)
3. Sedimentation rate (inflammation, abscess)
4. Incision and drainage (I & D) and culture
5. Bone scan (metastatic carcinoma)
6. Barium swallow (diverticulum, cardiac size)
7. Mammogram
8. Sonogram (cystic mass)
9. Aortogram (aortic aneurysm)
10. Mediastinoscopy (neoplasm of mediastinum)
11. CT scan of mediastinum or chest (neoplasm, aneurysm, abscess)

Pictures

Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.

More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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