Mike Zuckerburg: A 28-Year-Old Male With a Fever and Pleuritic Chest Pain of Acute Onset

Learning Objectives

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Learn the common causes of chest pain.
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Learn the common causes of hand deformity.
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Develop an understanding of the unique anatomy of the chest wall.
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Develop an understanding of the differential diagnosis of devil’s grip.
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Learn to identify the underlying diseases associated with devil’s grip.
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Learn the clinical presentation of devil’s grip.
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Learn how to examine the chest and chest wall.
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Learn how to use physical examination to identify devil’s grip.
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Develop an understanding of the treatment options for devil’s grip.

Mike Zuckerburg

Mike Zuckerburg is a 28-year-old computer technician with the chief complaint of, “I am sicker than a dog.” Mike explained, “Everyone in my office is sick; and here it is, the end of summer, but I got it the worst. I can barely get a breath in, it hurts so bad. Doc, I literally cannot take a deep breath. Do you think I have pneumonia? I really feel punk.” Mike was a longstanding patient of the practice. One of the retired partners had delivered him and taken care of him until retirement, and I added Mike to my patient list. Mike stated that he had what he thought was a summer cold. It seemed that everybody in the office got sick at once, but over the last couple of days, he became increasingly sicker with a cough and severe pain every time he took a breath.

Mike noted that the pain was worse with coughing, deep breathing, or any movement of the chest wall. He tried using a heating pad and extra-strength Tylenol without much success. I asked about Motrin, but he said it “ate a hole in my stomach. Doc, what do you think is going on here? I think this is about the sickest I have ever been.” I could see that Mike looked systemically ill, and it was obvious that he was really worried. I tried to reassure him that we would figure it out.

Mike denied any antecedent chest wall trauma, or pulmonary or cardiac disease. I asked what made the pain better and he said, “Nothing really helps. I spend all my time trying to not cough or breathe too deeply because it hurts so much.” Mike said he had a fever for the last couple of days, usually around 100; the highest was 100.6. “I didn’t have chills, but I don’t have much of an appetite, a little diarrhea. I really don’t feel good.” I asked Mike to decribe his pain, and he said it felt like someone was sticking a knife in his chest and twisting it each time he took a breath. “It feels like I’ve got a stitch or a catch every time I breathe. I am sleeping in my recliner so I can get a little rest. It just hurts too much to lie down.”

On physical examination, Mike had a mild fever at 100.2 orally. His respirations were 18, and his pulse was 86 and regular. He was normotensive with a blood pressure of 126/74. Mike’s oxygen saturation on room air was 98%. His head, eyes, ears, nose, throat (HEENT) exam was unremarkable, nothing to suggest strep throat. His cardiac exam was completely normal. Peripheral pulses were full. His pulmonary exam was a different story. He had a loud friction rub anteriorly on the left. It was easy to hear, even over all of the upper airway secretions he had from not coughing. His thyroid was normal, and there was no adenopathy. His abdominal examination revealed no abnormal mass or organomegaly. There was no costovertebral angle (CVA) tenderness or peripheral edema. Mike’s low back examination was unremarkable. Visual inspection of the chest wall was unremarkable with no costochondral swelling or costochondritis. Examination of his major joints revealed no acute arthritis. A careful neurologic examination revealed no evidence of peripheral or entrapment neuropathy, and the deep tendon reflexes were normal. There was no evidence of thrombophlebitis.

Key Clinical Points—What’s Important and What’s Not

The History

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History of acute onset of fever and right-sided pleuritic chest pain
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History of multiple coworkers suffering from a febrile illness
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No history of previous significant chest pain
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Mild fever for 48 hours
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No history of chills
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Exacerbation of pain with coughing, movement of the chest wall, and deep breathing
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Sleep disturbance