What is the best course of action for a 31-year-old female with left-sided chest pain and left shoulder pain that worsens with deep breathing, coughing, burping, or laying down, with normal vitals, a normal electrocardiogram (ECG) showing normal sinus rhythm with sinus arrhythmia, and no history of heavy lifting or injury?

Urgent Care Management of Pleuritic Chest Pain in a Young Woman

This patient most likely has acute pericarditis and should receive NSAIDs (ibuprofen 600-800mg TID or colchicine 0.6mg BID) after ruling out life-threatening causes with a chest X-ray and D-dimer. 1, 2

Immediate Diagnostic Workup

The clinical presentation—pleuritic chest pain worsening with deep breathing, coughing, and lying down—strongly suggests pericarditis, but you must first exclude life-threatening conditions before making this diagnosis. 3, 1

Required Testing in Urgent Care:

• Chest X-ray immediately to rule out pneumothorax, pneumonia, and assess for widened mediastinum (aortic dissection) 1, 2
• D-dimer if available, as levels <500 ng/mL make aortic dissection and pulmonary embolism unlikely 3
• Repeat vital signs including oxygen saturation and blood pressure in both arms to detect pulse/BP differentials suggestive of aortic dissection 3, 1

The normal ECG showing sinus rhythm with sinus arrhythmia is reassuring but does not exclude pericarditis, as ECG changes (diffuse ST elevation, PR depression) may be absent early or in mild cases. 2

Key Clinical Features Supporting Pericarditis

This patient's presentation is classic for acute pericarditis:

• Sharp, pleuritic chest pain that worsens with inspiration and coughing 3, 2
• Positional component: worse when lying down, typically improves leaning forward 2
• Left-sided radiation to shoulder (phrenic nerve irritation) 2
• Young age (31 years) with no cardiac risk factors 4
• Normal vital signs excluding hemodynamic instability 1

What Makes Life-Threatening Causes Unlikely

Acute Coronary Syndrome is unlikely because:

• Pain is sharp and pleuritic, not the gradual-onset pressure/squeezing typical of ACS 3, 1
• Pain is positional (worse lying down), which is nonischemic 3
• Worsens with burping, suggesting esophageal/pericardial involvement rather than myocardial ischemia 3
• No associated diaphoresis, dyspnea, nausea, or radiation to jaw/arm 3, 1

Aortic Dissection is unlikely because:

• No sudden-onset "ripping" or "tearing" quality 3, 2
• Normal vital signs without pulse differentials or BP discrepancies 3
• Gradual onset over 3 days rather than sudden 3

Pulmonary Embolism is unlikely because:

• No dyspnea or tachycardia (present in >90% of PE cases) 2
• No risk factors mentioned (recent surgery, immobilization, malignancy) 2

Urgent Care Management Algorithm

If chest X-ray and D-dimer are normal or low-risk:

1. Diagnose acute pericarditis clinically based on characteristic pleuritic, positional chest pain 2

2. Initiate anti-inflammatory therapy:

   • Ibuprofen 600-800mg TID for 1-2 weeks, OR
   • Colchicine 0.6mg BID for 3 months 2

3. Discharge with outpatient cardiology follow-up within 1 week for echocardiogram to assess for pericardial effusion 1

4. Provide return precautions: fever, worsening dyspnea, syncope, or hemodynamic instability warrant immediate ED evaluation 1

If chest X-ray shows infiltrate, effusion, or pneumothorax, OR if D-dimer is elevated (>500 ng/mL):

• Transfer to ED immediately for CT chest with IV contrast to evaluate for PE or other serious pathology 1, 2

If any high-risk features develop (hemodynamic instability, severe dyspnea, syncope, new ECG changes):

• Activate EMS for immediate ED transfer 3, 1

Common Pitfalls to Avoid

• Do not assume all pleuritic chest pain is benign musculoskeletal pain without imaging to exclude pneumothorax and infiltrates 1, 2
• Do not rely on ECG alone to diagnose or exclude pericarditis, as sensitivity is limited 2
• Do not discharge without clear return precautions, as pericarditis can progress to cardiac tamponade 1
• Do not use nitroglycerin response as a diagnostic test, as it relieves esophageal spasm and other noncardiac conditions 3, 2

Why Not Costochondritis?

While costochondritis is common in young adults with chest pain, this patient lacks the hallmark feature of reproducible tenderness on palpation of costochondral joints. 4, 2 The prominent positional component (worse lying down) and worsening with burping point more toward pericarditis or esophageal involvement rather than pure musculoskeletal pathology. 3, 2