In Medicine we talk of REFERRED PAIN. This means there is pain at one place and the origin of the pain is not near by organ ,but somewhere farther out. Sometimes there may be pain in upperpart of the belly on right side and that could be from liver of gall bladder .But then there could be right shoulder pain or shoulder blade and that could be from not from shoulder problem but could be from gall bladder. The nerve supply to gall bladder and right shoulder is common and so one could have right shoulder pain and have no shoulder problem ,but have gall bladder problem. Again this is when someone has gall bladder attack. This not ordinary shoulder pain, but intense pain. That brings me to story for today.
I saw this new patient in the office. She was mid 70ies and was sent to me by a psychiatrist. She had moved here from a town 250 miles away from our place. She had complaints of breast pain or as she described -' my breasts are hurting - tender.' The primary care had done the work up and had chest x- ray and EKG and had found nothing. When the pain continued and there was no etiology found for that , he sent her to a psychiatrist. He evaluated her and found no depression and no psychiatric cause . So then he sent her to me. I got her old records from primary care physician and also x- ray report , which was normal. When I asked her about the pain, she said there is pain as if there is a band of chest tightness. and she held her hands on both sides of the breasts. There was nothing in her physical examination. Her blood pressure was normal and her lungs were clear. And the oxygen saturation was ok . I reviewed her primary care records. I also had records from previous physician. I realized that she has been complaining about this pain for more that 6 months . The previous physician had asked a chest surgeon to evaluate and he had done a procedure called MEDIASTINOSCOPY. In this procedure under anesthesia a scope is introduced through incision above sternum and then biopsies are done . They found nothing. But she continued to have pain/ pressure. One thing that I noticed that she had lost weight . In last 8 months she had lost 60 lbs. The weight recorded from previous physician and 2-3 visits by local PCP showed that she was gradually losing weight.
I decided to order a new CT scan. I knew something was wrong and there was a problem in her chest . I the CT scan did confirm my suspicion. She had a mass in the posterior part of the mediastinum and the tumor was invading and pinching nerve . This was causing the 'Band like pain'. The tumor was causing the pain and was also causing the weight loss. The mediastinoscopy cannot reach back side structures -near spine , where that was causing the pressure on nerves and causing pain .So we did the biopsy of that mass . We started treatment with radiation and the pain was resolved .
This pain on the chest wall and breasts is called referred pain as it was due to pressure on nerves from tumor which was farther from the breasts or chest wall.
