What is the appropriate evaluation and management plan for a patient presenting with intermittent left hand and arm pain, burning sacral pain, and dull ache with sharp stabs that worsens with inspiration?

Evaluation and Management of Pleuritic Pain with Radicular Features

This patient requires immediate ECG and chest radiography to exclude life-threatening causes, followed by targeted musculoskeletal and neurological evaluation if initial workup is negative.

Immediate Life-Threatening Exclusions

The pain worsening with inspiration demands urgent evaluation for potentially fatal conditions before considering benign etiologies:

• Pulmonary embolism presents with dyspnea, pleuritic chest pain, tachycardia, and tachypnea in >90% of cases 1, 2
• Pneumothorax manifests as pleuritic pain on inspiration with unilateral absent breath sounds and hyperresonant percussion 1, 2, 3
• Pericarditis causes sharp, pleuritic pain that worsens supine and improves sitting forward, with widespread ST-elevation and PR depression on ECG 1, 2, 4
• Acute coronary syndrome can present with pleuritic features in 13% of patients, though sharp pain worsening with inspiration makes ischemia less likely 2, 4

Critical First Steps

• Obtain ECG within 10 minutes of presentation to identify STEMI, pericarditis patterns, or signs of pulmonary embolism 1, 2
• Perform chest radiography to evaluate for pneumothorax, pneumonia, pleural effusion, or widened mediastinum 1, 2
• Measure cardiac troponin as soon as possible in acute presentations to exclude myocardial injury 1, 2
• Assess vital signs including oxygen saturation, as tachycardia and tachypnea occur in >90% of pulmonary embolism cases 1, 2

Physical Examination Priorities

Focus on distinguishing pleuritic from musculoskeletal and radicular pain:

• Chest wall palpation for costochondral tenderness, though 7% of patients with reproducible chest wall pain still have acute coronary syndrome 1, 2
• Auscultation for unilateral decreased breath sounds (pneumothorax/effusion), pleural friction rub (pleural inflammation), or crackles (pneumonia) 1, 2
• Neurological examination of left upper extremity for dermatomal sensory loss, motor weakness, or reflex changes suggesting radiculopathy 1
• Spinal examination with palpation of sacral/lumbar spine for tenderness and assessment of range of motion 1

Important Caveat

Do not assume reproducible chest wall tenderness excludes serious pathology, as a significant minority of patients with palpable tenderness have life-threatening conditions 1, 2

Differential Diagnosis Framework

If Initial Cardiac/Pulmonary Workup Negative:

Musculoskeletal causes become most likely:

• Costochondritis/Tietze syndrome presents with tenderness of costochondral joints on palpation and pain worsening with inspiration 1, 2
• Intercostal myofascial injury causes musculoskeletal chest pain secondary to trauma to connective tissues between ribs 1
• Precordial catch syndrome (Texidor's twinge) manifests as brief, sharp discomfort associated with inspiration 1

Radicular pain features (left hand/arm involvement):

• Cervical radiculopathy causing dermatomal pain distribution in left upper extremity 1
• Thoracic radiculopathy potentially explaining chest wall pain with radicular features 1
• Herpes zoster produces pain in dermatomal distribution triggered by touch, with characteristic unilateral dermatomal rash 1, 2

Sacral/low back pain component:

• Lumbar radiculopathy or sacroiliac joint dysfunction causing burning pain worsened by prolonged sitting 1
• Myofascial pain syndrome with referred pain patterns 1

Management Algorithm

Step 1: Emergency Evaluation (First 10-30 Minutes)

• ECG, chest X-ray, troponin, vital signs 1, 2
• If positive for life-threatening cause → immediate specialty consultation and treatment 1

Step 2: If Emergency Workup Negative

• Detailed musculoskeletal examination with palpation of chest wall, spine, and assessment of range of motion 1
• Neurological examination of left upper extremity for radicular features 1
• Consider simple imaging: spine X-rays if trauma suspected or inflammatory markers (ESR) if inflammatory disease considered 1

Step 3: Biopsychosocial Assessment

The British Pain Society recommends evaluating psychosocial factors that predict chronic disability, particularly for pain lasting >6 weeks 1:

• Pain catastrophizing (describing pain as "unbearable" or "ripping and tearing") indicates high emotional reactivity requiring cognitive-behavioral approaches 1
• Functional impact on work, sleep, and daily activities 1, 5
• Yellow flags for chronicity risk including fear-avoidance behaviors and passive coping strategies 1

Step 4: Treatment Based on Diagnosis

For musculoskeletal/pleuritic pain:

• NSAIDs as first-line pharmacologic treatment 1
• Physical therapy with emphasis on posture, breathing exercises, and gradual activity progression 1
• Avoid prolonged sitting given symptom exacerbation pattern 1

For radicular features:

• Neuromodulators (gabapentin, pregabalin) for neuropathic pain components 1
• Physical therapy focused on nerve mobilization and strengthening 1

For chronic pain (>3 months):

• Cognitive-behavioral therapy particularly if pain catastrophizing present 1
• Multidisciplinary pain management combining pharmacologic and behavioral approaches 1
• Avoid opioids as they are associated with poorer long-term outcomes and do not reduce suffering in chronic non-cancer pain 1

Critical Pitfalls to Avoid

• Never delay transfer to ED for troponin testing in office settings if acute coronary syndrome suspected 1
• Do not use nitroglycerin response as diagnostic criterion, as relief does not confirm or exclude myocardial ischemia 2
• Do not assume sharp, pleuritic pain excludes cardiac ischemia entirely, though it makes it less likely 2, 4
• Avoid continuous cycle of investigations without addressing biopsychosocial factors in chronic presentations 1
• Do not normalize chronic pain or offer work disability/opioids as primary solutions, as these worsen long-term outcomes 1

Follow-Up Strategy

• Reassess within 6 months if pain persists despite initial management 1
• Monitor for development of chronic pain (present in 20-25% of patients with initial symptoms) 5
• Serious causes rarely emerge during long-term follow-up if not apparent after initial evaluation 5
• Use validated symptom scales to measure treatment response objectively 5