What are the possible causes of right‑sided pleuritic chest pain on deep breathing and how should it be evaluated and managed?

Right-Sided Pleuritic Chest Pain: Evaluation and Management

Right-sided chest pain worsening with deep breathing requires immediate systematic evaluation to exclude life-threatening causes—particularly pulmonary embolism, pneumothorax, and pneumonia—before considering benign musculoskeletal etiologies. 1, 2

Immediate Life-Threatening Causes to Rule Out First

Pulmonary Embolism (Most Critical)

• PE is the most serious cause of pleuritic pain, occurring in 5-21% of emergency presentations with this symptom 3
• Classic presentation includes dyspnea (80-85% of cases), pleuritic chest pain (52%), tachycardia, and tachypnea (present in >90% of cases) 1, 2
• Right-sided pleuritic pain typically indicates distal emboli causing pleural irritation from alveolar hemorrhage 1
• Pleural effusion develops in 46% of PE cases and is frequently hemorrhagic, contributing to ongoing pain 1, 4

Pneumothorax

• Presents with the classic triad: dyspnea, sharp pleuritic pain on inspiration, and unilateral absent breath sounds with hyperresonant percussion 2
• Right-sided primary spontaneous pneumothorax is particularly common in tall, thin young males 5

Pneumonia with Pleural Involvement

• Localized right-sided pleuritic pain with fever, productive cough, regional dullness to percussion, and egophony 2
• May present with pleural friction rub—a biphasic, coarse, grating sound heard during both inspiration and expiration 1, 4

Acute Coronary Syndrome (Atypical Presentation)

• Critical pitfall: 13% of patients with pleuritic pain have acute myocardial ischemia 1, 2
• Sharp, pleuritic features do NOT exclude cardiac ischemia 2, 4
• More common in elderly, women, diabetics, and those with renal insufficiency 4

Initial Diagnostic Approach (First 10 Minutes)

Mandatory Immediate Testing

• 12-lead ECG within 10 minutes to identify STEMI, pericarditis patterns (widespread ST-elevation with PR depression), or PE-related changes 2, 4
• Chest X-ray (PA and lateral) to evaluate for pneumothorax, pneumonia, pleural effusion, or masses 1, 2
• Cardiac troponin measurement as soon as possible to exclude myocardial injury 2, 4
• Vital signs assessment: tachycardia and tachypnea are present in >90% of PE cases 2, 4

Risk Stratification for Pulmonary Embolism

• Apply Wells criteria or other validated clinical decision rules to categorize pretest probability 1, 2
• Assess critical risk factors: immobilization in past 4 weeks, history of DVT/PE, malignancy, recent surgery, prolonged travel 1
• For low-to-intermediate probability: obtain D-dimer using age- and sex-specific cutoffs 1, 2
• For high probability or positive D-dimer: proceed directly to CT pulmonary angiography 1, 2

Physical Examination Pearls

Key Findings to Elicit

• Pleural friction rub: biphasic, sounds like "creaking leather or walking on fresh snow," louder than crackles, not cleared by coughing—indicates pleural inflammation 1, 4
• Unilateral decreased breath sounds: suggests pneumothorax or large pleural effusion 2, 4
• Chest wall tenderness on palpation: suggests costochondritis BUT 7% of patients with reproducible chest wall pain still have acute coronary syndrome—never assume this excludes serious pathology 1, 2, 4
• Localized tenderness may paradoxically occur with pleurisy due to spinal reflex mechanisms, not just musculoskeletal causes 6

Common Benign Causes (Only After Excluding Life-Threatening Etiologies)

Viral Pleurisy

• Viruses are common causative agents: Coxsackieviruses, respiratory syncytial virus, influenza, parainfluenza, Epstein-Barr virus 3
• Typically presents with preceding viral prodrome, sharp localized pain worsening with breathing 3

Costochondritis/Tietze Syndrome

• Tenderness of costochondral joints on palpation 2
• However, reproducible tenderness does NOT rule out serious disease 1, 2, 4

Post-Pneumonia Pleuritic Pain

• Sharp pain following pneumonia can indicate residual pleural inflammation 1
• Must rule out empyema (occurs in up to 10% of bacteremic pneumococcal pneumonia), which requires urgent drainage 1
• Repeat chest radiograph is mandatory for persistent or worsening pain after pneumonia 1

Critical Pitfalls to Avoid

• Never assume reproducible chest wall tenderness excludes serious pathology—7% of these patients have ACS 1, 2, 4
• Nitroglycerin response is NOT a valid diagnostic test—relief does not confirm or exclude myocardial ischemia 2, 4
• Do not delay transfer for troponin testing in office settings—patients with suspected ACS should be transported urgently to ED by EMS 2
• Sharp, pleuritic pain does NOT exclude cardiac ischemia—this is a dangerous assumption 2, 4
• A normal chest X-ray does NOT exclude PE—sensitivity is only 2-60% for certain conditions 2

Disposition Algorithm

Immediate EMS Transport to Emergency Department

• Any concern for PE (based on Wells criteria), pneumothorax, ACS, or aortic dissection 2
• Hemodynamic instability, severe dyspnea, or hypoxia 2

Urgent Outpatient Evaluation (Same Day)

• Fever with pleuritic pain (possible pneumonia) 3
• Persistent pain without clear benign etiology 1

Outpatient Management Acceptable

• Clear viral prodrome with typical pleuritic pain, normal vital signs, normal ECG, and low Wells score 3
• Confirmed costochondritis with negative cardiac workup 2
• Treat with NSAIDs for pain management in virally triggered or nonspecific pleuritic chest pain 3

Special Considerations

In Smokers or Patients >50 Years

• Document radiographic resolution with repeat chest X-ray six weeks after initial treatment for pneumonia 3
• Consider lung cancer, COPD exacerbation, or pneumothorax from lung bullae 1

Occupational Exposures

• Asbestos exposure can cause acute pleural effusion with fever and severe pleuritic pain 1, 7
• Consider hypersensitivity pneumonitis or occupational asthma 1