What is the appropriate workup for a patient with pleuritic chest pain (pain upon inspiration)?

Workup for Pleuritic Chest Pain (Pain with Inspiration)

Immediate Life-Threatening Exclusions First

The initial workup for pleuritic chest pain must prioritize ruling out life-threatening conditions—pulmonary embolism, acute coronary syndrome, pneumothorax, pericarditis, and aortic dissection—before considering benign causes, even though sharp pain worsening with inspiration is unlikely to be cardiac ischemia. 1

Initial Assessment (Within 10 Minutes)

• Obtain vital signs immediately: blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation to assess hemodynamic stability 2
• Perform 12-lead ECG within 10 minutes of presentation to evaluate for STEMI, pericarditis (diffuse ST elevation), or signs of right heart strain (suggesting PE) 2, 3
• Draw cardiac troponin immediately upon presentation, even though pleuritic pain characteristics make ischemia less likely 2, 3

Focused History and Physical Examination

Key historical features to elicit:

• Sharp chest pain increasing with inspiration and lying supine is unlikely ischemic and typically indicates acute pericarditis 1
• Sudden onset of severe "ripping" pain radiating to the back suggests aortic dissection and requires immediate imaging 1
• Pleuritic pain with dyspnea or tachycardia raises concern for pulmonary embolism 2, 4
• Localized chest wall tenderness may suggest musculoskeletal causes, but be aware that pleurisy itself can cause chest wall tenderness through spinal reflex mechanisms 5

Physical examination priorities:

• Assess for diaphoresis, tachypnea, tachycardia, hypotension, crackles, S3 gallop, or murmurs indicating ACS complications 2
• Evaluate for unilateral decreased breath sounds (pneumothorax) or friction rub (pericarditis or pleurisy) 4
• Check for signs of deep vein thrombosis if PE is suspected 2

Risk Stratification and Diagnostic Algorithm

High-Risk Features Requiring Immediate Intervention

Any of the following mandate urgent evaluation and hospital admission: 2

• Abnormal ECG changes suggestive of ischemia or pericarditis
• Elevated cardiac troponin levels
• Hemodynamic instability or signs of heart failure
• Hypoxemia requiring supplemental oxygen
• Age >52 years with dyspnea and pleuritic chest pain 6

Pulmonary Embolism Evaluation (Most Common Life-Threatening Cause)

Pulmonary embolism is found in 5-20% of patients presenting with pleuritic pain to emergency departments. 4

• Use validated clinical decision rules (Wells score or Geneva score) to determine pretest probability 6
• Obtain D-dimer with age-adjusted cutoffs if low-to-intermediate probability 6
• Proceed to CT pulmonary angiogram if D-dimer elevated or high clinical probability 2, 6

Cardiac Evaluation

• Serial troponin measurements at 3-6 hours if initial troponin negative but symptoms persist 3
• Serial ECGs if initial ECG nondiagnostic but clinical suspicion remains 3
• A single normal troponin does not exclude cardiac disease, particularly in women and elderly patients who may present with atypical symptoms 3

Additional Diagnostic Testing Based on Clinical Suspicion

Chest radiography for all patients to evaluate for:

• Pneumothorax
• Pneumonia (consolidation)
• Pleural effusion
• Widened mediastinum (aortic dissection) 4

If aortic dissection suspected:

• CT chest with contrast for definitive diagnosis 2

If pericarditis suspected:

• Echocardiography to assess for pericardial effusion 6

Diagnosis of Pleurisy (After Exclusion of Life-Threatening Causes)

Once pulmonary embolism, ACS, pneumothorax, pericarditis, and aortic dissection are excluded, the diagnosis of pleurisy can be made. 4

• Viral pleurisy is among the most common causes of pleuritic chest pain after life-threatening conditions are ruled out 4
• Additional diagnostic testing may be pursued in selected patients based on clinical context (autoimmune workup, tuberculosis testing, etc.) 4

Common Pitfalls to Avoid

• Do not dismiss pleuritic chest pain as benign without proper workup—pulmonary embolism remains a significant risk 4
• Do not rely on chest wall tenderness alone to diagnose musculoskeletal pain—pleurisy itself can cause localized tenderness through spinal reflex mechanisms 5
• Do not use nitroglycerin response as a diagnostic criterion for cardiac vs. non-cardiac pain, as other conditions (esophageal spasm) may respond similarly 1
• Women and elderly patients require heightened vigilance as they more frequently present with atypical symptoms 3

Treatment Approach

For confirmed pleurisy after exclusion of serious causes:

• Pain management with NSAIDs 4
• Treatment targeted at underlying cause (antibiotics for bacterial pneumonia, anticoagulation for PE if confirmed, etc.) 6, 4