In a 21‑year‑old woman presenting with dyspnea, pleuritic chest pain on inspiration, borderline hypotension, normal oxygen saturation, tachycardia, no sweating and fatigue, what is the most likely diagnosis and appropriate treatment?

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Last updated: September 29, 2026 • View editorial policy

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Diagnosis and Treatment

This 21-year-old woman most likely has pleuritic chest pain from a benign cause (viral pleurisy or musculoskeletal pain) rather than pulmonary embolism, and should receive symptomatic treatment with NSAIDs while ruling out serious causes through targeted investigation.

Clinical Assessment

The presentation includes pleuritic chest pain, dyspnea, tachycardia (99 bpm), borderline BP (100/70), normal oxygen saturation (99%), and fatigue. According to the British Thoracic Society guidelines, PE can be excluded in the absence of all three of: tachypnea (>20/min), pleuritic pain, and arterial hypoxemia 1. This patient has pleuritic pain but normal oxygen saturation—the respiratory rate is the critical missing piece of information.

Key Diagnostic Criteria

The guidelines emphasize that young women whose only risk factor is oral contraception who present with isolated pleuritic chest pain are very unlikely to have PE if they have a respiratory rate <20/min plus a normal chest radiograph 1. This is particularly relevant here.

**PE is rare if age <40 with no risk factors, and estrogens are only a minor risk factor** 1. The guidelines note that predisposing factors are found in 80-90% of PE patients, with the commonest being immobilization >1 week, previous VTE, recent surgery, and lower limb fractures 1.

Immediate Diagnostic Workup

Perform these investigations immediately 1:

  1. Record respiratory rate - This is critical for risk stratification
  2. Chest radiography - To exclude pneumothorax, pneumonia, and assess for other causes
  3. ECG - To evaluate for myocardial infarction, pericarditis, or signs of RV strain
  4. Arterial blood gas measurements - Though SpO2 is normal, this confirms oxygenation status

D-dimer Testing Strategy

If a reliable D-dimer test is available, normal levels exclude PE 1. However, D-dimer should only be ordered if clinical probability assessment suggests low or intermediate risk. Given her age and lack of major risk factors, this patient likely falls into low-intermediate probability.

Treatment Algorithm

If PE is Suspected (High Clinical Probability)

Heparin should be started on the basis of high or intermediate clinical suspicion before the diagnosis of PE is clarified 1:

  • Initial dose: 5,000-10,000 IU IV bolus (or 80 IU/kg weight-adjusted)
  • Maintenance: 1,300 IU/hour (or 18 IU/kg/hour weight-adjusted)
  • Target APTT: 1.5-2.5 times control (45-75 seconds)
  • Monitor APTT: 4-6 hours after initial bolus, then 6-10 hours after dose changes, then daily 1

Thrombolytic therapy is NOT indicated unless the patient becomes hemodynamically unstable with systemic hypotension 1. This patient's BP of 100/70 does not meet criteria for thrombolysis.

If PE is Excluded (Most Likely Scenario)

Treat as pleuritic chest pain from viral or nonspecific cause 2, 3:

  • NSAIDs for pain management (e.g., ibuprofen 400-600 mg every 6-8 hours)
  • Reassurance and supportive care
  • Follow-up if symptoms persist or worsen

Critical Pitfalls to Avoid

  1. Do not over-investigate low-risk patients: The guidelines warn that PE is both overdiagnosed and underdiagnosed in clinical practice 1. With normal oxygen saturation, young age, and no major risk factors, extensive imaging may not be warranted.

  2. Do not start anticoagulation without adequate clinical suspicion: The risks of anticoagulation are well-recognized, and the benefit:risk ratio may be unfavorable in low-probability cases 1.

  3. Do not miss alternative diagnoses: Pericarditis, pneumothorax, pneumonia, and myocardial infarction must be excluded through ECG and chest X-ray before settling on a benign diagnosis 2, 3.

  4. Document respiratory rate: This single vital sign is crucial for risk stratification but is frequently omitted 1.

Specific Next Steps

If respiratory rate <20/min AND chest X-ray is normal: PE is very unlikely in this young woman with oral contraception as her only risk factor 1. Treat symptomatically with NSAIDs.

If respiratory rate ≥20/min OR abnormal chest X-ray: Proceed with D-dimer testing. If D-dimer is elevated, perform lung scanning within 24 hours or CT pulmonary angiography 1, 4, 5.

If clinical suspicion remains high despite negative initial tests: Consider leg vein imaging for DVT, as 80% of PE cases are associated with DVT 5.

References

3
Research

Pleurisy.

American family physician, 2007

5
Guideline

acr appropriateness criteria® suspected pulmonary embolism: 2022 update.

Journal of the American College of Radiology, 2022

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