What is the appropriate evaluation and management for a patient with intermittent pulsing chest pain around the left nipple line, sharp in nature, exacerbated by deep breathing, without shortness of breath, and with normal Body Mass Index (BMI)?

Evaluation and Management of Pleuritic Left Chest Pain

This presentation is most consistent with musculoskeletal chest pain, specifically costochondritis, and the patient should undergo focused physical examination with palpation of the costochondral joints, obtain an ECG to exclude cardiac causes, and can be managed conservatively without urgent cardiac testing if examination reproduces the pain and ECG is normal. 1

Initial Clinical Assessment

The key clinical features pointing toward a benign etiology include:

• Sharp, pleuritic quality worsened by deep breathing strongly suggests a non-cardiac cause, as this pattern is characteristic of musculoskeletal or pleural pathology rather than myocardial ischemia 1, 2
• Intermittent nature with complete resolution makes life-threatening conditions like acute coronary syndrome, pulmonary embolism, or aortic dissection less likely 1
• Absence of dyspnea significantly reduces probability of pulmonary embolism (which presents with dyspnea in >90% of cases) and pneumothorax 1, 2
• Normal BMI and lack of systemic symptoms (no fever, diaphoresis, or hemodynamic instability) further support a benign diagnosis 1

Critical Physical Examination Maneuvers

Palpate the costochondral joints systematically along the left chest wall - tenderness to palpation that reproduces the patient's pain strongly suggests costochondritis or Tietze syndrome 1, 2

However, a critical caveat: 7% of patients with reproducible chest wall tenderness may still have acute coronary syndrome, so chest wall tenderness alone does not definitively exclude cardiac pathology 2

Additional examination elements to assess:

• Vital signs - tachycardia and tachypnea are present in >90% of pulmonary embolism cases 1, 2
• Auscultation - unilateral absence of breath sounds suggests pneumothorax; pleural friction rub indicates pleural inflammation 1, 2
• Cardiac examination - presence of S3, murmurs, or friction rub would suggest cardiac or pericardial pathology 1

Mandatory Initial Testing

Obtain a 12-lead ECG immediately - this is a Class I recommendation for any patient with chest pain in the office setting unless a clearly noncardiac cause is evident 1, 3

The ECG serves to exclude:

• ST-segment elevation myocardial infarction (must be identified within 10 minutes) 1, 3
• Pericarditis (widespread ST-elevation with PR depression) 2
• Signs of pulmonary embolism (though ECG is often normal) 1, 2

If ECG is unavailable in your office, refer the patient to the emergency department to obtain one 1

Risk Stratification Algorithm

LOW-RISK Features (Present in This Case):

• Pleuritic, positional pain exacerbated by breathing 1, 2
• Pain reproducible with palpation 1, 2
• Intermittent with complete resolution 1
• No dyspnea, diaphoresis, or radiation to arms/jaw 1
• Normal vital signs 1, 2

HIGH-RISK Features (Absent - But Screen For):

• Prior abnormal stress test (LR 3.1 for ACS) 4
• Peripheral arterial disease (LR 2.7 for ACS) 4
• Pain radiating to both arms (LR 2.6 for ACS) 4
• Diaphoresis, tachycardia, hypotension 1

Management Pathway

For patients determined to be low-risk with normal ECG and reproducible chest wall tenderness:

• No urgent cardiac testing is needed - this is explicitly stated in the 2021 AHA/ACC guidelines 1
• Conservative management with NSAIDs for costochondritis is appropriate 1
• Reassurance and return precautions - instruct patient to return immediately if pain becomes constant, radiates to arms/jaw, or is accompanied by dyspnea or diaphoresis 1, 3

If any uncertainty exists or high-risk features are present:

• Transport urgently to the emergency department by EMS (not personal vehicle) 1, 3
• Do not delay transfer for troponin testing in the office - this is a Class III (Harm) recommendation 1
• Cardiac troponin should be measured as soon as possible after ED arrival 1, 3

Common Pitfalls to Avoid

Do not assume pleuritic pain excludes cardiac ischemia - while sharp pain worsened by inspiration makes ischemia less likely, it does not completely rule it out, and 13% of ACS patients may present with pleuritic pain 2, 5

Do not use nitroglycerin response as a diagnostic test - relief with nitroglycerin does not confirm or exclude myocardial ischemia 3

Do not rely solely on chest wall tenderness - 7% of patients with reproducible tenderness on palpation still have acute coronary syndrome 2

Do not skip the ECG - even in seemingly obvious musculoskeletal cases, an ECG is mandatory to exclude life-threatening cardiac causes 1, 3

Disposition Decision

This patient can be managed as an outpatient if:

• Physical examination reproduces pain with costochondral palpation 1, 2
• ECG is normal 1, 3
• No high-risk features are present 1
• Patient understands return precautions 3

Follow-up in 1-2 weeks if symptoms persist to reassess and consider alternative diagnoses 1