What could be causing my unilateral chest, shoulder, back, neck, and underarm pain, along with difficulty breathing and pain when moving?

Immediate Emergency Evaluation Required

You need immediate emergency department evaluation with ECG and cardiac biomarkers within 10 minutes of arrival, as your unilateral pain pattern with dyspnea and pleuritic features does not exclude acute coronary syndrome (ACS), and life-threatening conditions including pulmonary embolism, aortic dissection, and pneumothorax must be ruled out urgently. 1, 2

Why This Requires Emergency Evaluation

Your symptom constellation is concerning because:

• Pain with deep breathing (pleuritic pain) does NOT exclude cardiac causes: While pleuritic pain is listed as "not characteristic" of myocardial ischemia, 13% of patients with confirmed ACS present with pleuritic qualities, and 7% have pain reproducible with palpation yet still have acute cardiac events 1

• Unilateral radiation patterns occur in ACS: Pain radiating to shoulder, back, neck, and underarm matches documented cardiac pain patterns, particularly in women and atypical presentations 1, 2, 3

• Dyspnea with exertion is a high-risk symptom: Unexplained dyspnea alone carries more than twice the mortality risk of typical angina and increases sudden cardiac death risk 4-fold, even without chest pain 1

Life-Threatening Conditions to Exclude First

The differential diagnosis includes:

Cardiac Causes

• Acute coronary syndrome: Symptoms may radiate to arm, jaw, neck, or back; dyspnea can be the primary presentation without prominent chest discomfort 1, 2
• Pericarditis: Sharp pain worsening with breathing and lying supine, improving when leaning forward 4

Pulmonary Emergencies

• Pulmonary embolism: Acute dyspnea with pleuritic chest pain, particularly with unilateral distribution 1, 4
• Pneumothorax: Sudden onset unilateral chest pain with dyspnea and pleuritic features 1

Vascular Emergency

• Aortic dissection: Sudden "ripping" or "tearing" pain radiating to back 1, 4

Critical Actions Upon ED Arrival

Within 10 minutes: 1, 2

• 12-lead ECG obtained and interpreted
• Cardiac troponin measurement initiated
• Continuous cardiac monitoring with defibrillation capability
• Chewable aspirin 162-325 mg administered (unless contraindicated) 1

High-Risk Features That Lower Threshold for Cardiac Workup

You are at higher risk if you have: 2, 3

• Age >50 years (especially women)
• Diabetes mellitus (autonomic dysfunction causes atypical presentations)
• Hypertension, hyperlipidemia, or smoking history
• Family history of premature coronary disease
• Known cardiovascular disease

Women specifically present more frequently with atypical symptoms including back pain, neck pain, shoulder pain, nausea, and dyspnea rather than classic substernal chest pressure. 2, 3

Common Diagnostic Pitfalls to Avoid

• Never assume pleuritic pain is non-cardiac: 13% of ACS patients have pleuritic features 1
• Never assume reproducible pain with palpation excludes ACS: 7% of patients with pain fully reproduced on palpation have acute cardiac events 1
• Never rely on nitroglycerin response: NTG relieves symptoms in 35% of patients with active CAD but also in 41% without CAD 1, 3
• Never assume "GI cocktail" response excludes ACS: Antacid relief does not predict absence of cardiac disease 1

If Cardiac Causes Are Excluded

Only after ECG, troponin, and appropriate imaging exclude emergencies should musculoskeletal causes be considered: 1, 4

Musculoskeletal Diagnoses

• Costochondritis: Most common cause (42% of musculoskeletal chest pain); reproducible tenderness at costochondral junctions 1, 4
• Intercostal muscle strain: Pain with movement and lifting 1
• Cervical radiculopathy: Neck pain radiating to shoulder and arm 5, 6

Distinguishing Features of Benign Musculoskeletal Pain

Pain that varies with: 1

• Respiration and body position
• Local palpation producing exact pain reproduction
• Well-localized to specific chest wall area
• Accompanied by focal tenderness

Do Not Delay

Call 911 or go immediately to the emergency department rather than waiting or seeking outpatient evaluation. 1 Transport by ambulance is preferred over private vehicle, as cardiac monitoring and treatment can begin en route. 1

The 17% mortality reduction with early treatment means 23 lives saved per 1000 patients per hour of delay. 1 Your symptoms warrant immediate professional evaluation regardless of whether they ultimately prove cardiac or non-cardiac in origin.