How to assess pleuritic chest pain?

Assessment of Pleuritic Chest Pain

A focused cardiovascular examination should be performed initially in patients with pleuritic chest pain to aid in the diagnosis of potentially serious causes such as pulmonary embolism, pneumothorax, pneumonia, or pericarditis. 1

Initial Evaluation

History

• Characterize the pain:
  • Timing: sudden vs. gradual onset
  • Quality: sharp, stabbing, or burning
  • Location and radiation
  • Aggravating factors: specifically worsening with inspiration
  • Alleviating factors
  • Associated symptoms: dyspnea, cough, fever, hemoptysis
• Risk factors assessment:
  • Thromboembolic risk factors (immobility, surgery, cancer, oral contraceptives)
  • Smoking history
  • Recent respiratory infections
  • History of cardiac or pulmonary disease
  • Medication history (certain drugs can cause pleural effusions) 1

Physical Examination

• Vital signs: tachypnea, tachycardia, hypotension, fever
• Respiratory examination:
  • Decreased breath sounds
  • Pleural friction rub
  • Dullness to percussion (effusion)
  • Hyperresonance (pneumothorax)
• Cardiovascular examination:
  • Signs of right heart failure
  • Pericardial friction rub
  • Murmurs
• Signs of deep vein thrombosis (leg swelling, tenderness)

Diagnostic Approach

Immediate Testing (within 10 minutes of presentation)

• 12-lead ECG to rule out myocardial infarction and evaluate for pericarditis 2
• Pulse oximetry
• Chest radiography to assess for:
  • Pneumonia (infiltrates)
  • Pneumothorax
  • Pleural effusion
  • Elevated diaphragm 1

Laboratory Tests

• Complete blood count
• Basic metabolic panel
• Cardiac biomarkers (troponin)
• D-dimer (if PE suspected)
• Arterial blood gas analysis (if respiratory distress)

Additional Imaging Based on Initial Findings

1. Suspected Pulmonary Embolism:

   • D-dimer testing as initial screen 3
   • CT pulmonary angiography if D-dimer positive or high clinical suspicion
   • Consider V/Q scan if CT contraindicated

2. Suspected Pneumothorax:

   • Upright chest X-ray
   • CT chest if X-ray negative but high clinical suspicion 2

3. Suspected Pleural Effusion:

   • Diagnostic thoracentesis for unilateral effusions 1
   • Send pleural fluid for:
     • Protein and LDH (transudate vs. exudate)
     • pH
     • Gram stain and culture
     • Cytology
     • AFB stain if TB suspected 1

4. Suspected Pericarditis:

   • Echocardiography to assess for effusion 2

Differential Diagnosis

Life-Threatening Causes

1. Pulmonary Embolism (PE)

   • Most common serious cause (5-21% of pleuritic chest pain cases) 4
   • Typically presents with:
     • Sudden onset dyspnea (often disproportionate to effusion size)
     • Pleuritic chest pain (present in 75% of PE cases with effusion) 3
     • Tachypnea and tachycardia
     • Risk factors for thromboembolism

2. Pneumothorax

   • Sudden onset of sharp pain
   • Dyspnea
   • Unilateral decreased breath sounds
   • Hyperresonance to percussion

3. Acute Coronary Syndrome

   • May present with pleuritic features
   • Risk factors for coronary artery disease
   • ECG changes
   • Elevated cardiac biomarkers

4. Aortic Dissection

   • Severe, tearing pain
   • Pulse differentials
   • Widened mediastinum on chest X-ray 1

Common Causes

1. Pneumonia

   • Fever, cough, sputum production
   • Localized chest pain
   • Consolidation on chest X-ray

2. Pericarditis

   • Central chest pain that worsens when supine
   • Pericardial friction rub
   • Diffuse ST elevation and PR depression on ECG 2

3. Viral Pleurisy

   • Common cause after excluding serious conditions
   • May follow viral respiratory infection
   • Common viral agents: Coxsackieviruses, RSV, influenza, parainfluenza 4

4. Musculoskeletal Pain

   • Tenderness of costochondral joints
   • Pain reproducible with palpation
   • Normal chest X-ray

Management Approach

Immediate Management

• Stabilize hemodynamically unstable patients
• Provide supplemental oxygen if hypoxemic
• Analgesia appropriate to the diagnosis

Specific Management Based on Diagnosis

1. Pulmonary Embolism:

   • Anticoagulation with heparin or LMWH
   • Consider thrombolysis for massive PE with hemodynamic compromise

2. Pneumothorax:

   • Observation for small, stable pneumothoraces
   • Needle aspiration or chest tube for larger or symptomatic pneumothoraces

3. Pneumonia:

   • Appropriate antibiotics based on likely pathogens
   • Supportive care (oxygen, hydration)
   • Pain control with acetaminophen or NSAIDs 2

4. Pericarditis:

   • NSAIDs as first-line therapy
   • Colchicine to prevent recurrence 2

5. Viral Pleurisy:

   • NSAIDs for pain management
   • Supportive care 4

Special Considerations

• In patients with persistent symptoms, smokers, and those older than 50 years with pneumonia, repeat chest radiography 6 weeks after initial treatment 4
• For undiagnosed pleural effusions, consider pulmonary embolism as a potential cause 3
• In patients under 40 years with pleuritic chest pain and pleural effusion, pulmonary embolism is the most common cause 3

Pitfalls to Avoid

• Assuming chest pain that worsens with inspiration is always benign or musculoskeletal
• Failing to consider pulmonary embolism in patients with pleuritic chest pain
• Relying solely on clinical impression without appropriate diagnostic testing
• Missing cardiac causes of pleuritic-appearing chest pain
• Overlooking medication-induced pleural disease