What could be causing shoulder pain on the back side, accompanied by burping, in a patient with a history of hypertension?

Urgent Cardiac Evaluation Required for Possible Acute Coronary Syndrome

This patient requires immediate emergency department evaluation for acute coronary syndrome (ACS), as the combination of shoulder pain radiating to the back, burping (belching), weakness, and hypertension history represents a classic atypical presentation of myocardial ischemia or infarction.

Critical Red Flags Present

This symptom constellation meets multiple criteria for ACS identification established by the ACC/AHA:

• Pain radiating to the back and shoulders is specifically listed as a cardinal symptom requiring immediate ACS protocol initiation 1
• "Unexplained indigestion, belching, epigastric pain" are recognized atypical presentations of myocardial ischemia 1
• Weakness and dizziness are emergency symptoms requiring immediate triage assessment 1
• History of hypertension is a major cardiovascular risk factor that increases ACS likelihood 1

Why This Is NOT Musculoskeletal Shoulder Pain

The presence of burping (belching) with shoulder pain fundamentally changes the diagnostic picture:

• Pure musculoskeletal shoulder pathology does not cause gastrointestinal symptoms like belching 2, 3
• The combination of shoulder pain with systemic symptoms (weakness, burping) suggests visceral rather than somatic pain origin 4
• Women and elderly patients frequently present with atypical chest pain and symptoms rather than classic substernal chest pressure 1

Immediate Actions Required

Emergency Department Triage Protocol 1

1. Obtain stat ECG immediately upon presentation - do not delay for complete history 1
2. Draw cardiac biomarkers (troponin I or T) at presentation and repeat at 6 hours to differentiate unstable angina from NSTEMI 1
3. Continuous cardiac monitoring for arrhythmias 1

Brief Targeted History 1

• Previous history of coronary artery disease, angina, MI, or revascularization procedures
• Nitroglycerin use and response
• Other cardiovascular risk factors: smoking, hyperlipidemia, diabetes, family history
• Current medications, particularly antihypertensive compliance

Physical Examination Focus 1

• Blood pressure measurement in both arms
• Cardiovascular assessment for signs of heart failure (pulmonary edema, elevated JVP)
• Neurologic assessment to exclude stroke as alternative presentation
• Fundoscopic examination if time permits (assesses chronicity of hypertension) 1

Differential Diagnosis Priority

Most Likely: Acute Coronary Syndrome 1

The most common cause of UA/NSTEMI is reduced myocardial perfusion from coronary artery narrowing caused by thrombus on disrupted atherosclerotic plaque 1. The atypical presentation with shoulder/back pain and belching is well-documented, particularly in:

• Patients with diabetes (autonomic dysfunction causes atypical presentations) 1
• Elderly patients (may present with generalized weakness rather than chest pain) 1
• Women (more frequently present with atypical symptoms than men) 1

Alternative Serious Diagnoses to Consider

Hypertensive emergency 1: If blood pressure is severely elevated (>180/120 mmHg), assess for:

• Acute end-organ damage (cardiac, renal, neurologic) 1
• Symptoms include headache, visual disturbances, chest pain, dyspnea, and gastrointestinal complaints (nausea, abdominal pain) 1
• However, hypertensive emergency alone does not typically cause isolated shoulder pain with belching 1

Aortic dissection 1: Less likely but catastrophic if missed:

• Presents with severe tearing back pain
• Blood pressure differential between arms
• Requires immediate CT angiography if suspected 1

Pulmonary pathology 4: Pneumonia or pulmonary embolism can present with shoulder pain, but would typically include:

• Cough, fever, shortness of breath
• Pleuritic chest pain
• Abnormal lung auscultation 4

Common Pitfalls to Avoid

1. Do not assume this is musculoskeletal shoulder pain simply because the chief complaint is "shoulder pain" - the associated burping and weakness are critical discriminating features 1, 4

2. Do not delay ECG and cardiac workup to complete a musculoskeletal shoulder examination 1

3. Do not treat blood pressure aggressively before ruling out ACS - if this is myocardial ischemia, blood pressure may be elevated as a compensatory response and should not be rapidly lowered 1

4. Do not discharge with musculoskeletal diagnosis without negative serial troponins and ECG 1

Disposition

• If troponins elevated or ECG shows ischemic changes: Admit for ACS management with antiplatelet therapy, anticoagulation, and cardiology consultation 1

• If initial troponins and ECG negative: Observe for 6-hour repeat troponin before considering discharge 1

• If all cardiac workup negative: Then and only then consider alternative diagnoses including musculoskeletal shoulder pathology, but maintain high suspicion given atypical presentation pattern 1, 2