What is the best course of action for an elderly female patient, who is postoperative from a hernia repair, presenting to the emergency room (ER) with right mid-back pain radiating to the chest, left shoulder, and left neck, which worsens with deep breathing?

Emergency Management of Postoperative Chest Pain with Pleuritic Features

This elderly female requires immediate evaluation for acute coronary syndrome (ACS) and pulmonary embolism (PE), followed by urgent imaging to rule out diaphragmatic hernia complication—all three diagnoses are life-threatening in the postoperative setting and demand rapid, systematic exclusion.

Immediate Life-Threatening Diagnoses to Exclude

Acute Coronary Syndrome

• Elderly women presenting with chest pain radiating to the shoulder, neck, and back must be evaluated for ACS as the first priority 1
• Women commonly present with atypical symptoms including back pain, jaw and neck pain, and accompanying symptoms more frequently than men 1
• Obtain a stat 12-lead ECG immediately upon triage for any patient with chest pain radiating to neck, jaw, shoulders, or back 1
• Draw cardiac biomarkers (troponin I or T) immediately, with repeat sampling at least 6 hours apart to definitively exclude myocardial injury 1
• The pain pattern described (radiating to left shoulder and neck, worsening with deep breath) overlaps with both cardiac and non-cardiac etiologies, making ECG and biomarkers mandatory 1

Pulmonary Embolism

• Recent surgery (hernia repair "a few days ago") places this patient at high risk for venous thromboembolism
• Pleuritic chest pain (pain that increases with deep breathing) is a classic presentation of PE
• The postoperative period represents peak risk for thromboembolic complications
• If ACS is excluded by ECG and initial troponin, proceed immediately to PE evaluation with D-dimer and/or CT pulmonary angiography based on clinical probability

Diaphragmatic Hernia Complications

Clinical Suspicion

• Right mid-back pain radiating through the chest in a postoperative hernia patient raises concern for diaphragmatic hernia or injury 1
• Right-sided diaphragmatic hernias are frequently missed (delayed diagnosis in 50% of cases) and can present with nonspecific respiratory and gastrointestinal symptoms 1
• Pleuritic pain (worsening with deep breath) is consistent with diaphragmatic pathology 1
• The recent surgical manipulation may have unmasked or caused a diaphragmatic defect

Diagnostic Approach

• Order chest X-ray (anteroposterior and lateral) as the initial diagnostic study for suspected diaphragmatic hernia in patients with respiratory symptoms 1
• However, recognize that chest X-ray has poor sensitivity (2-60% for left-sided, 17-33% for right-sided hernias) and normal films occur in 11-62% of cases 1
• If clinical suspicion persists despite normal chest X-ray, proceed immediately to CT scan with contrast enhancement of chest and abdomen (strong recommendation, moderate-quality evidence) 1
• CT is the gold standard for diagnosing diaphragmatic hernia 1

Urgent Surgical Considerations

• Undetected diaphragmatic hernia can cause bowel strangulation, perforation, peritonitis, sepsis, and multi-organ failure with high mortality 1
• Delayed diagnosis beyond 24 hours significantly increases mortality 2
• Right-sided hernias have worse prognosis when complications develop due to delayed recognition 1

Algorithmic Approach

Step 1: Immediate Triage (Within 5 Minutes)

• Obtain vital signs and assess hemodynamic stability 1
• Stat 12-lead ECG 1
• Establish IV access and draw cardiac biomarkers (troponin) 1
• Assess oxygen saturation

Step 2: Risk Stratification (Within 15 Minutes)

• If ECG shows ST-segment depression, T-wave inversion, or ST-elevation → activate ACS protocol immediately 1
• If ECG is non-diagnostic but pain is ongoing → serial ECGs every 15-30 minutes and continuous monitoring 1
• Calculate PE risk score (Wells criteria or similar) given recent surgery

Step 3: Imaging Strategy (Within 30-60 Minutes)

• Chest X-ray (PA and lateral) to evaluate for diaphragmatic hernia, pneumothorax, or other thoracic pathology 1
• If troponin negative and ECG non-ischemic but pleuritic pain persists → CT chest/abdomen with IV contrast to evaluate for PE and diaphragmatic hernia simultaneously 1
• Do not delay CT imaging if diaphragmatic hernia complication is suspected—imaging delays worsen outcomes 2

Step 4: Definitive Management

• If strangulated hernia identified → immediate surgical consultation for emergency repair 2
• If ACS confirmed → cardiology consultation and appropriate antiplatelet/anticoagulation therapy 1
• If PE confirmed → anticoagulation per institutional protocol

Critical Pitfalls to Avoid

• Never assume chest pain in elderly women is non-cardiac—women are at high risk for underdiagnosis of ACS, and traditional risk assessments underestimate their risk 1
• Do not attribute all pleuritic pain to musculoskeletal causes in the postoperative setting—PE and diaphragmatic complications are life-threatening 1
• Never delay surgery for additional imaging when strangulation is clinically suspected—elapsed time from symptom onset to surgery is the most important prognostic factor 2
• Do not dismiss right-sided diaphragmatic pathology as rare—right-sided hernias are more commonly missed and have delayed diagnosis in 50% of complicated cases 1
• Recognize that "sudden onset ripping chest pain" would suggest aortic dissection, but this patient's gradual onset with pleuritic features makes that less likely (though not impossible) 1

Special Considerations for Elderly Postoperative Patients

• Elderly patients may have atypical presentations of serious conditions due to altered pain perception and multiple comorbidities 1
• Recent hernia surgery increases risk for both thromboembolic events and unrecognized diaphragmatic injury 1, 2
• Emergency surgery in elderly patients carries higher complication rates than elective repair, making early diagnosis crucial 3
• Postoperative complications in hernia patients can include bowel compromise that was not initially apparent 2