What is the recommended treatment and further evaluation for a patient with worsening pain upon deep inspiration?

Evaluation and Treatment of Pain Worse with Deep Inspiration

For patients presenting with chest pain that worsens with deep inspiration, a focused evaluation for pulmonary embolism, pneumothorax, pneumonia, or pericarditis should be prioritized as these conditions are the most likely diagnoses.

Initial Assessment

History and Physical Examination

• Key symptoms to assess:

  • Timing and onset of pain (sudden vs. gradual)
  • Quality (sharp, pleuritic, pressure-like)
  • Radiation (to back, shoulder, arm)
  • Associated symptoms (fever, cough, dyspnea)
  • Risk factors for thromboembolism (immobility, surgery, cancer)

• Physical examination focus:

  • Vital signs (tachycardia, tachypnea, hypotension)
  • Respiratory examination (decreased breath sounds, crackles)
  • Cardiovascular examination (friction rub, S3, murmurs)
  • Chest wall tenderness
  • Signs of DVT in lower extremities

Initial Diagnostic Testing

1. 12-lead ECG within 10 minutes of presentation 1
2. Chest X-ray to evaluate for pneumonia, pneumothorax, or widened mediastinum
3. Laboratory tests:
   • Cardiac troponin
   • D-dimer (if PE is suspected)
   • Complete blood count
   • Basic metabolic panel

Diagnostic Algorithm Based on Clinical Presentation

For Suspected Pulmonary Embolism

• When to suspect: Sudden onset dyspnea, pleuritic chest pain, risk factors for thromboembolism 2
• Diagnostic approach:
  1. Calculate clinical probability (Wells or Geneva score) 2
  2. D-dimer testing (if low/intermediate probability)
  3. CT pulmonary angiography (CTPA) for definitive diagnosis 3
  4. Consider bedside echocardiography to assess for right ventricular dysfunction in unstable patients 4, 5

For Suspected Pneumothorax

• When to suspect: Sudden onset pain, unilateral decreased breath sounds 1
• Diagnostic approach:
  1. Chest X-ray
  2. If negative but high suspicion, consider CT chest

For Suspected Pericarditis

• When to suspect: Positional pain (worse when supine), friction rub 1
• Diagnostic approach:
  1. ECG (diffuse ST elevation, PR depression)
  2. Echocardiography to assess for effusion

For Suspected Pneumonia

• When to suspect: Fever, cough, localized chest pain, crackles 1
• Diagnostic approach:
  1. Chest X-ray
  2. Blood cultures if indicated

Treatment Recommendations

For Pulmonary Embolism

• Initial management:
  • Anticoagulation with heparin or LMWH 5
  • Risk stratification using clinical scores and evidence of right ventricular dysfunction 5
  • Consider thrombolysis for high-risk patients with hemodynamic instability 5

For Pneumothorax

• Treatment options:
  • Small, stable: Observation with follow-up imaging
  • Large or symptomatic: Needle aspiration or chest tube placement

For Pericarditis

• Treatment approach:
  • NSAIDs as first-line therapy
  • Colchicine to prevent recurrence
  • Monitor for effusion development

For Pneumonia

• Treatment approach:
  • Appropriate antibiotics based on likely pathogens
  • Supportive care (oxygen, hydration)
  • Pain control with acetaminophen or NSAIDs

Special Considerations

Aortic Dissection

Although less likely to present with pain worse on inspiration, this life-threatening condition must be considered in patients with:

• Severe, sudden-onset chest or back pain
• Pulse differentials or widened mediastinum on CXR 1
• If suspected, immediate CT angiography of chest/abdomen/pelvis is recommended 1

Unstable Patients

For hemodynamically unstable patients:

• Immediate ECG to rule out STEMI 1
• Point-of-care ultrasound/echocardiography can rapidly identify life-threatening causes 1, 6
• Transfer to emergency department by EMS if evaluated in outpatient setting 1

Follow-up Recommendations

• Patients with confirmed diagnosis should receive condition-specific follow-up
• Low-risk patients with negative workup may need reassessment if symptoms persist
• Consider cardiology referral for patients with recurrent symptoms or concerning features

Pitfalls to Avoid

• Assuming all pleuritic chest pain is musculoskeletal or benign
• Delaying ECG beyond 10 minutes in acute presentations
• Missing PE in patients with normal oxygen saturation
• Failing to consider multiple diagnoses (e.g., pneumonia with small PE)
• Discharging patients without clear diagnosis or follow-up plan

By following this structured approach, clinicians can efficiently evaluate and treat patients presenting with chest pain that worsens with deep inspiration, focusing on the most likely and potentially serious causes.