From the Guidelines
For a patient with worsening shortness of breath, dry cough, and right shoulder pain on exertion, the most appropriate initial test is a chest radiograph, which can evaluate for comorbidities, complications, and alternative diagnoses. This recommendation is based on the American College of Radiology Appropriateness Criteria for chronic dyspnea of noncardiovascular origin 1.
The patient's symptoms suggest a potential pulmonary or cardiac issue, and a chest radiograph is a reasonable first step to guide further imaging decisions. Additional tests, such as pulmonary function tests, electrocardiogram (ECG), and cardiac enzymes (troponin), may be necessary to rule out other conditions, including obstructive or restrictive lung diseases and acute coronary syndrome.
Some key points to consider when evaluating this patient include:
- The presence of dry cough and shortness of breath, which could indicate a pulmonary issue such as chronic obstructive pulmonary disease (COPD) or interstitial lung disease (ILD) 1
- The right shoulder pain on exertion, which could be referred pain from a cardiac issue or a musculoskeletal problem
- The need for a comprehensive physical examination, complete blood count, and basic metabolic panel to evaluate for other potential causes of the patient's symptoms
Further testing, such as a high-resolution CT scan of the chest or a CT pulmonary angiogram, may be warranted based on the results of the initial evaluation and the patient's clinical presentation. However, a chest radiograph is the most appropriate initial test, as it can provide valuable information about the patient's pulmonary and cardiac status and guide further diagnostic decisions 1.
From the Research
Diagnostic Tests for Worsening Shortness of Breath, Dry Cough, and Right Shoulder Pain on Exertion
The patient's symptoms of worsening shortness of breath, dry cough, and right shoulder pain on exertion require a thorough diagnostic evaluation to determine the underlying cause. Based on the available evidence, the following tests should be considered:
- Chest radiography to rule out pneumonia, pneumothorax, or other pulmonary abnormalities 2
- Electrocardiography to evaluate for myocardial infarction, pericarditis, or atrial fibrillation 2, 3
- Troponin assays to assess for cardiac damage 2
- D-dimer test to evaluate for pulmonary embolism (PE) 4, 2
- Computed tomographic pulmonary angiography (CTPA) or ventilation-perfusion scan to confirm PE diagnosis 4, 2
- Echocardiography to assess pulmonary arterial pressure and rule out other cardiac abnormalities 4, 5
- Perfusion lung scan to evaluate ventilatory abnormalities and alveolar dead space ventilation 5
- B-type natriuretic peptide (BNP) test to assess for heart failure 4
- Validated clinical decision rules, such as the Wells score or Geneva score, to guide the diagnostic evaluation for PE 2
Additional Considerations
The patient's symptoms and test results should be evaluated in the context of their medical history, physical examination, and risk factors for various conditions. A multidisciplinary approach may be necessary to manage complex cases with multiple potential diagnoses 3. The diagnostic evaluation should be tailored to the individual patient, and the choice of tests should be guided by the clinical presentation and the likelihood of various conditions.