What is the recommended treatment for a patient with right upper chest pain, normal EKG (electrocardiogram), no tenderness, and difficulty taking deep breaths, with imaging findings showing mild atelectasis, trace left pleural effusion, and no pulmonary embolus?

Management of Right Upper Chest Pain with Normal EKG and Mild Atelectasis

This patient requires immediate evaluation for acute coronary syndrome (ACS) despite a normal initial EKG, followed by symptomatic management of pleuritic pain and close observation for evolving cardiac or pulmonary pathology. 1, 2

Immediate Assessment and Risk Stratification

Obtain a 12-lead ECG within 10 minutes of presentation and draw high-sensitivity cardiac troponin immediately, as normal initial EKG does not exclude ACS, particularly in patients with atypical presentations. 1, 2 The European Society of Cardiology emphasizes that approximately 70% of patients with acute ischemic events may have normal or inconclusive initial ECG findings. 3

• Repeat troponin measurements at 3,6, and 9-12 hours after symptom onset to detect delayed rise indicating myocardial injury, as a single negative troponin does not exclude cardiac pathology. 1, 2
• Perform serial ECGs every 2-4 hours during the observation period to detect evolving ischemic changes. 1
• Initiate continuous multi-lead ECG monitoring for arrhythmias and ST-segment changes throughout the evaluation period. 2

Focused Physical Examination

Assess for hemodynamic instability including hypotension, pulmonary rales, new murmurs, and signs of cardiogenic shock, as these are critical high-risk features requiring immediate intervention. 1

• Palpate the chest wall to determine if pain is reproducible with pressure over costochondral junctions, which may suggest musculoskeletal etiology, but this finding does not exclude cardiac causes and should not alter the cardiac workup. 1, 2
• Document specific chest pain characteristics: sharp pain that increases with inspiration and lying supine is unlikely ischemic and suggests pericarditis or pleuritic pain. 2
• Examine for pulse differentials between extremities to evaluate for aortic dissection, though sensitivity is only 30%. 1

Echocardiographic Evaluation

Strongly consider urgent echocardiography to assess for wall motion abnormalities, pericardial effusion, and structural abnormalities, as the European Association of Cardiovascular Imaging recommends echocardiography for evaluation of chest pain in patients with haemodynamic instability or when diagnosis remains unclear. 3

• Echocardiography can exclude major myocardial ischemia if performed during ongoing chest pain (>45 minutes duration) and shows no wall motion abnormalities. 3
• Normal resting echocardiography cannot definitively rule out transient ischemia, especially in patients with chest pain of short duration. 3

Management of Atelectasis and Pleural Effusion

The mild atelectasis and trace left pleural effusion identified on imaging are likely incidental findings that do not fully explain the right-sided chest pain, as atelectasis was found on the left side while symptoms are right-sided. 4

• Atelectasis commonly causes dyspnea and hypoxemia through ventilation-perfusion mismatch, with mean PaO2 of 73 mmHg in patients with three or more segments of atelectasis. 4
• Encourage deep breathing exercises, incentive spirometry, and adequate pain control to prevent worsening atelectasis and promote lung re-expansion. 4
• The trace pleural effusion does not require specific intervention unless it enlarges or becomes symptomatic. 3, 5

Critical Differential Diagnoses to Exclude

Pulmonary embolism has been definitively excluded by imaging, which is reassuring as PE commonly presents with chest pain and pleural effusion. 3, 6, 5

• Acute pericarditis should be considered if pain is sharp, increases with inspiration and lying supine, and improves when leaning forward. 3, 2
• Pneumothorax must be excluded as it presents with acute chest pain and dyspnea; review imaging carefully for this finding. 2
• Musculoskeletal pain remains a diagnosis of exclusion after cardiac and pulmonary causes have been ruled out. 1

Observation Period and Disposition

Admit to a monitored bed (telemetry unit) for 9-12 hour observation period given the combination of chest pain, difficulty breathing, and need for serial cardiac biomarkers. 1, 2

• High-risk features requiring aggressive management include: recurrent or persistent chest pain, elevated troponin levels, hemodynamic instability, new arrhythmias, and dynamic ECG changes. 1, 2
• Discharge criteria after observation period: negative serial troponin measurements at 9-12 hours, no dynamic ECG changes, no recurrent symptoms, hemodynamic stability, and reassuring echocardiogram if obtained. 1, 2

Symptomatic Management

Provide adequate analgesia for pleuritic chest pain to facilitate deep breathing and prevent further atelectasis, using NSAIDs if no contraindications exist. 3

• Administer aspirin 250-500 mg immediately if ACS cannot be excluded, unless contraindicated. 2
• Provide supplemental oxygen if oxygen saturation is reduced or patient appears dyspneic. 3

Critical Pitfalls to Avoid

Do not discharge based solely on normal initial EKG and imaging, as atypical presentations are common, particularly in older patients, women, and those with diabetes. 2

Do not attribute all symptoms to the mild atelectasis and trace effusion without completing cardiac evaluation, as these findings may be incidental and unrelated to the presenting complaint. 4

Do not delay cardiac workup to treat atelectasis, as the temporal sequence and laterality (right-sided pain with left-sided atelectasis) suggest these may be separate issues. 1, 2