What is the best course of action for a patient with right-sided anterior chest pain that worsens with inspiration?

Right-Sided Anterior Chest Pain Worse with Inspiration: Systematic Evaluation

The most critical first step is obtaining an ECG within 10 minutes and performing a focused physical examination to exclude life-threatening causes—particularly pulmonary embolism, pneumothorax, and acute coronary syndrome—before considering more benign diagnoses like costochondritis or pericarditis. 1

Immediate Life-Threatening Exclusions Required

The pleuritic nature of this pain (worse with inspiration) immediately raises concern for several emergent conditions that require rapid assessment:

Pulmonary Embolism

• Tachycardia and dyspnea occur in >90% of PE patients, with pain on inspiration being a hallmark feature 1
• Check vital signs immediately, particularly heart rate, respiratory rate, and oxygen saturation 1
• Assess for risk factors including recent immobilization, surgery, malignancy, or oral contraceptive use 1
• If tachycardia, dyspnea, or hypoxia are present with pleuritic chest pain, PE must be excluded urgently 1

Pneumothorax

• Dyspnea and pain on inspiration with unilateral absence of breath sounds are pathognomonic 1
• Perform immediate auscultation of both lung fields 1
• Right-sided location makes this particularly relevant 1
• Chest radiograph is indicated to evaluate for pneumothorax 1

Acute Coronary Syndrome

• While sharp chest pain that increases with inspiration and lying supine is unlikely related to ischemic heart disease, ACS must still be formally excluded 1, 2
• Obtain ECG within 10 minutes regardless of suspected diagnosis 2, 3
• Symptoms on the right side of the chest and sharp, stabbing pain can occur in patients with diabetes, women, and elderly patients presenting with ACS 1
• Measure cardiac troponin if any concern for ACS exists 2

Algorithmic Approach to This Patient

Step 1: Immediate Assessment (First 10 Minutes)

• Obtain 12-lead ECG within 10 minutes 1, 2
• Measure vital signs including oxygen saturation and blood pressure in both arms 2
• Perform focused cardiopulmonary examination, specifically listening for:
  • Unilateral decreased or absent breath sounds (pneumothorax) 1
  • Friction rub (pericarditis) 1
  • Tachycardia (PE or other serious pathology) 1

Step 2: Risk Stratification

High-risk features requiring immediate ED transfer by EMS include: 2

• Hemodynamic instability (hypotension, tachycardia) 2
• Hypoxia or respiratory distress 1
• New ECG abnormalities suggesting ischemia 2
• Unilateral absent breath sounds 1
• Associated diaphoresis, syncope, or severe dyspnea 2

Step 3: Consider Most Likely Diagnoses Based on Clinical Features

If Pain is Sharp, Pleuritic, and Positional:

Pericarditis is characterized by:

• Sharp, pleuritic chest pain that worsens when supine and improves when leaning forward 1, 3
• Fever may be present 1
• Friction rub on examination (though only present in one-third of cases) 1, 4
• Widespread saddle-shaped ST elevation with PR depression on ECG 3, 4
• Diagnosis requires at least 2 of 4 criteria: characteristic chest pain, friction rub, ECG changes, or pericardial effusion 3

Costochondritis/Chest Wall Pain presents with:

• Tenderness of costochondral joints on palpation 1, 2
• Pain reproducible with chest wall pressure 2
• Pain affected by palpation, breathing, turning, twisting, or bending 2
• Pain localized to a very limited area 1, 2

If Pain is Associated with Fever and Cough:

Pneumonia should be considered with:

• Fever, localized chest pain that may be pleuritic 1
• Regional dullness to percussion, egophony 1
• Friction rub may be present 1
• Chest radiograph is useful to evaluate for pulmonary causes 1

Critical Diagnostic Testing

Essential Initial Tests:

• 12-lead ECG within 10 minutes 1, 2
• Chest radiograph to evaluate for cardiac, pulmonary, and thoracic causes 1
• Cardiac troponin if any suspicion of ACS 2
• Oxygen saturation 2

Additional Testing Based on Clinical Suspicion:

• D-dimer if PE is suspected (levels <500 ng/mL make PE unlikely) 2
• Transthoracic echocardiography if pericarditis suspected to detect effusion 3
• CRP if pericarditis suspected to guide treatment duration 3

Management Based on Diagnosis

If Pericarditis is Confirmed:

• Ibuprofen 600-800mg three times daily for 1-2 weeks as cornerstone therapy 3
• Colchicine 0.6mg twice daily for 3 months reduces recurrence from 37.5% to 16.7% 3
• Admit if high-risk features present: fever >38°C, large effusion, elevated troponin, immunosuppression, or failure to respond to NSAIDs within 7 days 3

If Costochondritis is Diagnosed:

• NSAIDs for symptomatic relief 2
• Reassurance that this is a benign condition 2

Critical Pitfalls to Avoid

• Do not use nitroglycerin response as a diagnostic criterion—it relieves esophageal spasm and other noncardiac conditions 1, 2, 4
• Do not dismiss chest pain in women, elderly patients, or those with diabetes, as they frequently present with atypical symptoms including sharp or stabbing pain 1, 2
• Do not delay transfer to the ED for troponin or other diagnostic testing if high-risk features are present 2
• Absence of pericardial friction rub does not exclude pericarditis—it is only audible in one-third of patients 4
• Fleeting chest pain lasting only seconds is unlikely to be related to ischemic heart disease 1
• Positional chest pain is usually nonischemic (e.g., musculoskeletal) 1, 4