What are the next steps for a 55-year-old female with difficulty breathing, hypertension on Lercanidipine (generic name) and Losartan (generic name), rosacea, sharp chest pain partially alleviated by Ibuprofen (Advil) (generic name: Ibuprofen), undocumented fever, and specific pain locations, with an allergy to Etoricoxib?

Next Steps for 55-Year-Old Female with Difficulty Breathing and Chest Pain

This patient requires immediate evaluation for acute coronary syndrome (ACS) and other life-threatening causes of chest pain, including pulmonary embolism, pneumothorax, and aortic dissection, despite the musculoskeletal findings on examination. 1

Immediate Triage and Assessment

Obtain a 12-lead ECG within 10 minutes of evaluation to assess for cardiac ischemia or injury, as this is the most critical initial diagnostic test. 1, 2 The combination of difficulty breathing, continuous chest pain (8/10 severity), and undocumented fever in a hypertensive patient warrants urgent cardiac evaluation regardless of the musculoskeletal findings. 1

Critical History Elements to Clarify

• Characterize the chest pain more precisely: The description "as if being punched" needs further clarification regarding whether it is substernal, pressure-like, squeezing, or truly sharp and stabbing. 1
• Assess for radiation: Determine if pain radiates to the neck, jaw, arms, or back, which would increase suspicion for cardiac ischemia. 1
• Identify precipitating factors: Determine if the pain is related to exertion, emotional stress, or occurs at rest (which suggests ACS). 1
• Document associated symptoms: Specifically ask about diaphoresis, nausea, vomiting, palpitations, lightheadedness, or syncope, which are common with myocardial ischemia. 1
• Clarify the dyspnea: Determine if shortness of breath preceded the chest pain or occurred simultaneously, as this affects the differential diagnosis. 1

Essential Diagnostic Testing

Immediate Laboratory Studies

• High-sensitivity cardiac troponin to evaluate for myocardial injury. 1
• Complete blood count to assess for infection (given the fever) and anemia. 2
• Basic metabolic panel to evaluate renal function (important given her antihypertensive medications) and electrolyte abnormalities. 2
• D-dimer if pulmonary embolism is being considered based on clinical probability. 1

Imaging Studies

• Chest radiography to evaluate for pneumonia (given fever), pneumothorax, pulmonary edema, or mediastinal abnormalities. 1, 2
• Consider CT pulmonary angiography if clinical suspicion for pulmonary embolism is moderate to high based on risk stratification. 1

Risk Stratification Considerations

Factors Increasing Concern for ACS

• Age 55 years with hypertension increases cardiovascular risk. 1
• Severe pain (8/10) with minimal response to ibuprofen (only decreased to 7/10) suggests the pain may not be purely musculoskeletal. 1
• Associated dyspnea is a common symptom with myocardial ischemia, particularly in women. 1
• Fever with chest pain could represent pericarditis or myocarditis, both requiring urgent evaluation. 1

Musculoskeletal Findings Do Not Exclude Cardiac Disease

While the physical examination reveals reproducible pain with palpation and arm movements suggesting a musculoskeletal component, this does not rule out concurrent cardiac pathology. 1 The presence of chest wall tenderness has limited diagnostic value in excluding ACS. 1

Medication Considerations

Immediate Management Pending Workup

• Avoid further ibuprofen given her allergy to etoricoxib (another NSAID), which suggests potential NSAID hypersensitivity. 1 Cross-reactivity within NSAID classes is well-described, and severe reactions should prompt avoidance of the entire class. 1
• If ACS is suspected and no contraindications exist, administer aspirin (chewable or water-soluble) as soon as possible. 1 However, given the etoricoxib allergy, carefully assess for any history of aspirin sensitivity before administration. 1
• Consider sublingual nitroglycerin if blood pressure is adequate (>90 mmHg systolic) and there is no bradycardia, though relief with nitroglycerin is not diagnostic of ischemia. 1
• Provide adequate analgesia with opiates if pain is severe and cardiac workup is ongoing. 1

Blood Pressure Management

Her current antihypertensive regimen (lercanidipine and losartan) should be continued unless hemodynamically unstable. 1, 3 Monitor blood pressure closely, as both medications are appropriate for her hypertension with evidence-based cardiovascular benefits. 1, 3

Disposition Decision

Criteria for Hospital Admission

This patient requires hospital admission or prolonged observation based on: 1

• Severe chest pain with dyspnea of acute onset (1 day duration)
• Inability to definitively exclude ACS without serial troponins and observation
• Presence of fever with chest pain requiring evaluation for infectious or inflammatory cardiac conditions
• Cardiovascular risk factors (age, hypertension)

If Initial Workup is Negative

Even if initial ECG and troponin are negative, serial troponin measurements at 3 and 6 hours are necessary to exclude non-ST-elevation myocardial infarction. 1 The patient should remain under observation during this period.

Common Pitfalls to Avoid

• Do not dismiss cardiac causes based solely on reproducible chest wall tenderness—musculoskeletal and cardiac pain can coexist. 1
• Do not use response to nitroglycerin as a diagnostic criterion for cardiac ischemia, as it lacks specificity. 1
• Do not assume the pain is "atypical" or benign in a woman with cardiovascular risk factors—women are at risk for underdiagnosis of ACS. 1
• Do not administer NSAIDs for pain control given the etoricoxib allergy and potential for cross-reactivity. 1
• Do not delay ECG or cardiac biomarkers while pursuing musculoskeletal evaluation. 1

If Cardiac Workup is Definitively Negative

Only after excluding life-threatening causes should you consider:

• Costochondritis or chest wall syndrome as the primary diagnosis, given the reproducible pain with palpation and arm movements. 2
• Viral syndrome with myalgias, given the fever and chest wall pain.
• Trial of acetaminophen for pain control (avoiding NSAIDs due to allergy). 1
• Reassurance and outpatient follow-up with instructions to return immediately if symptoms worsen or change in character.