What could cause sudden sharp stabbing one-sided chest pain at the apex area when coughing or breathing deeply in an adult without other symptoms or shortness of breath?

Sudden Sharp Stabbing One-Sided Chest Pain at Apex with Deep Breathing or Coughing

This presentation is most consistent with pleuritic chest pain, likely from musculoskeletal causes (costochondritis) or pleuritis, but you must first exclude pulmonary embolism, pneumothorax, and pericarditis before attributing symptoms to benign causes. 1

Key Diagnostic Features That Point Away from Cardiac Ischemia

The characteristics described are not typical of acute coronary syndrome:

• Sharp, stabbing pain that worsens with breathing or coughing is pleuritic in nature and unlikely related to ischemic heart disease 1
• Pain localized to a very limited area (such as the cardiac apex) that can be pointed to with one finger is unlikely to represent myocardial ischemia 1
• Fleeting or brief episodes lasting only seconds are not characteristic of cardiac ischemia 1
• The absence of associated symptoms (no dyspnea, diaphoresis, nausea, or radiation) further reduces cardiac probability 1

Critical Life-Threatening Causes to Exclude First

Despite the non-cardiac features, you must systematically rule out dangerous conditions:

Pulmonary Embolism

• Sharp pleuritic chest pain can be the presenting feature of PE, particularly if associated with tachycardia (>100 bpm), tachypnea, or recent immobilization 2, 3
• Obtain vital signs immediately to assess for tachycardia, tachypnea, or oxygen desaturation 2, 3
• Apply clinical decision rules (Wells or Geneva score) to determine PE probability 3
• D-dimer with age-adjusted cutoffs if low-to-intermediate probability; proceed to CT pulmonary angiogram if elevated 3

Pneumothorax

• Primary spontaneous pneumothorax characteristically presents with acute sharp chest pain and is pleuritic in nature 4
• Physical examination should assess for decreased breath sounds, hyperresonance, and tracheal deviation 1

Pericarditis

• Sharp chest pain that increases with inspiration and lying supine suggests acute pericarditis rather than ischemia 1
• Obtain ECG within 10 minutes to evaluate for diffuse ST elevation and PR depression characteristic of pericarditis 1, 3

Diagnostic Algorithm

Step 1: Immediate Assessment

• Obtain vital signs (heart rate, respiratory rate, blood pressure, oxygen saturation) 2, 3
• Perform 12-lead ECG within 10 minutes to exclude STEMI, pericarditis, or right heart strain 1, 2, 3
• Measure cardiac troponin as soon as possible, even though pleuritic features make ischemia unlikely 1, 3

Step 2: Focused Physical Examination

• Palpate the chest wall and costochondral junctions to reproduce pain (suggests musculoskeletal origin) 1, 5, 6
• Auscultate lungs for decreased breath sounds (pneumothorax) or pleural friction rub (pleuritis/pericarditis) 1, 4
• Assess for reproducibility with chest wall movement or palpation 1, 5

Step 3: Risk Stratification

• If vital signs are normal, ECG shows no acute changes, and pain is fully reproducible with palpation, musculoskeletal cause (costochondritis) is most likely 5, 6
• However, note that 7% of patients with ACS had pain fully reproduced by palpation in the Multicenter Chest Pain Study, so reproducibility alone does not exclude cardiac disease 1

Most Likely Diagnoses in Order of Probability

1. Costochondritis/Musculoskeletal Chest Wall Pain

• Sharp, localized pain at the apex area that worsens with breathing or movement 5, 6
• Pain reproduced with palpation of costochondral junctions or chest wall 1, 5
• No systemic symptoms or hemodynamic compromise 5, 6

2. Pleuritis (Viral or Inflammatory)

• Pleuritic pain related to breathing movements 4
• May follow recent viral illness 4
• Pleural friction rub may be present on auscultation 4

3. Pericarditis

• Sharp pain that worsens with inspiration and lying supine 1
• May improve when sitting forward 1
• ECG shows characteristic changes (diffuse ST elevation, PR depression) 1

Critical Pitfalls to Avoid

• Never dismiss pleuritic chest pain as benign without proper workup, as pulmonary embolism remains a significant risk even with typical pleuritic features 2, 3
• Do not use nitroglycerin response as a diagnostic criterion, as esophageal spasm and other non-cardiac conditions also respond 1, 7
• In the Multicenter Chest Pain Study, acute ischemia was diagnosed in 22% of patients with sharp/stabbing pain and 13% with pleuritic features, so atypical presentations do not exclude ACS 1
• Women, elderly patients, and diabetics frequently present with atypical symptoms including sharp or stabbing pain 1, 2

When to Transfer to Emergency Department

Immediate ED transfer is required if:

• Any ECG abnormalities suggestive of ischemia, pericarditis, or right heart strain 2, 3
• Tachycardia >100 bpm with dyspnea (suggests PE) 2
• Hemodynamic instability (hypotension, syncope) 2
• Oxygen desaturation 3

Office management is appropriate if:

• Vital signs completely normal 2
• ECG normal 1
• Pain fully reproducible with chest wall palpation 5
• No risk factors for PE (recent immobilization, surgery, cancer, unilateral leg swelling) 2