What are the differential diagnoses and urgent work‑up recommendations for a 44‑year‑old woman with a one‑week intermittent pleuritic chest pain worsened by deep breathing and movement, described as throat heaviness and left lateral chest wall pain, without other associated symptoms?

Evaluation of One-Week Pleuritic Chest Pain in a 44-Year-Old Woman

Immediate Life-Threatening Exclusions Required First

Despite the week-long duration and pleuritic character, you must still obtain a 12-lead ECG within 10 minutes and measure high-sensitivity cardiac troponin immediately, because acute coronary syndrome can present atypically in women and the "heaviness in throat" descriptor raises concern for ischemic equivalents. 1, 2

• Women frequently present with atypical ACS symptoms including throat discomfort, nausea, and fatigue rather than classic substernal pressure, making cardiac exclusion mandatory even with pleuritic features. 1, 2
• Sharp or pleuritic chest pain does not exclude ACS; 13% of patients with pleuritic-quality pain have acute myocardial ischemia. 1, 2
• A normal physical examination does not rule out uncomplicated myocardial infarction. 1, 2

Pulmonary Embolism Must Be Considered

• One week of intermittent symptoms does not exclude pulmonary embolism; chronic thromboembolic disease can present with weeks of dyspnea and pleuritic chest pain. 1, 3, 4
• Pleuritic chest pain worsening with deep breathing is a hallmark PE presentation, occurring in 52% of confirmed cases. 1
• Tachycardia (>100/min) is present in >90% of PE patients and tachypnea (>20/min) in 70%. 1
• Check vital signs now: heart rate, respiratory rate, oxygen saturation, and blood pressure in both arms. 1, 2

Aortic Dissection Is Unlikely But Must Be Excluded

• The gradual onset over one week and pleuritic character make dissection improbable, but pulse and blood pressure differentials between arms must still be assessed. 1, 2
• Sudden "ripping" or "tearing" pain maximal at onset is characteristic of dissection; this patient's description does not match. 1, 2

Most Likely Diagnosis: Costochondritis or Musculoskeletal Pain

After excluding life-threatening causes, the combination of pleuritic chest pain worsening with movement and deep breathing over one week strongly suggests costochondritis, which accounts for 43% of chest pain presentations in primary care when cardiac causes are excluded. 1, 2

Diagnostic Features Supporting Musculoskeletal Origin

• Pain that worsens with movement of the chest wall, deep breathing, turning, or twisting is characteristic of costochondritis. 1, 2
• Palpate the costochondral junctions bilaterally; tenderness that reproduces the patient's pain confirms the diagnosis. 1, 2
• Pain localized to the left outer chest wall fits the typical distribution of costochondral inflammation. 1, 2
• One-week duration without progression or associated systemic symptoms (no fever, no dyspnea at rest, no diaphoresis) makes unstable angina unlikely. 1

Alternative Musculoskeletal Consideration

• If pain radiates to the interscapular region or medial scapular border, consider rhomboid muscle strain, which causes localized pain affected by shoulder movement. 5

Pericarditis Remains in the Differential

• Sharp, pleuritic chest pain is the classic presentation of acute pericarditis. 1, 2, 6
• Ask specifically: Does the pain worsen when lying flat and improve when leaning forward? This positional pattern is pathognomonic for pericarditis. 2, 6
• Auscultate carefully for a pericardial friction rub (present in only a subset of cases; absence does not exclude disease). 1, 2
• Check for fever, which commonly accompanies pericarditis. 1, 2
• The ECG may show diffuse ST-segment elevation with PR-segment depression if pericarditis is present. 6

Gastroesophageal Causes

• "Heaviness in the throat" may represent esophageal reflux or spasm. 1, 2
• Ask: Does the discomfort worsen after meals, at night, or when lying flat? Is it relieved by antacids? 1, 2, 6
• Esophageal spasm can produce chest pain that mimics cardiac ischemia and may even respond to nitroglycerin, so nitroglycerin response should not be used diagnostically. 1, 2

Algorithmic Diagnostic Approach

Step 1: Immediate Assessment (First 10 Minutes)

1. Obtain 12-lead ECG within 10 minutes. 1, 2, 6
2. Measure high-sensitivity cardiac troponin immediately. 1, 2
3. Record vital signs: heart rate, respiratory rate, oxygen saturation, blood pressure in both arms. 1, 2
4. Perform focused cardiovascular and pulmonary examination: assess for pulse differentials, new murmurs, pericardial rub, unilateral breath sounds, and chest-wall tenderness. 1, 2

Step 2: Risk Stratification Based on Initial Results

If ECG shows ST-elevation, new ischemic changes, or troponin is elevated:

• Activate emergency medical services for immediate transport to the emergency department. 2, 6
• Initiate dual antiplatelet therapy and anticoagulation. 2

If ECG is normal/nondiagnostic and initial troponin is normal:

• Repeat troponin at 3–6 hours to definitively exclude ACS. 1, 2
• Proceed with clinical assessment for non-ACS causes. 2

Step 3: Clinical Examination for Non-Cardiac Causes

• Palpate costochondral junctions bilaterally: Tenderness reproducing the patient's pain confirms costochondritis. 1, 2
• Assess positional variation: Ask the patient to lie supine, then lean forward. Pain that worsens supine and improves leaning forward indicates pericarditis. 2, 6
• Reproduce pain with chest-wall movement: Have the patient raise both arms overhead, twist the torso, and take a deep breath. Pain provoked by these maneuvers supports musculoskeletal origin. 1, 2

Step 4: Consider Pulmonary Embolism If Clinical Suspicion Persists

• Calculate a Wells score or use clinical gestalt to assess PE probability. 1, 3
• If tachycardia, tachypnea, or hypoxemia is present, measure D-dimer (if low-risk) or proceed directly to CT pulmonary angiography (if intermediate-to-high risk). 1, 2
• Critical pitfall: A negative CT pulmonary angiography does not exclude chronic thromboembolic disease; if clinical suspicion remains high, order ventilation-perfusion (V/Q) scintigraphy. 3

Step 5: Definitive Diagnosis and Management

If both troponins are normal, ECG is nonischemic, and chest-wall tenderness is present:

• Diagnose costochondritis. 1, 2
• Prescribe NSAIDs (e.g., ibuprofen 600–800 mg three times daily for 1–2 weeks). 2
• Advise temporary avoidance of movements that exacerbate pain. 2
• Provide reassurance that the condition is benign. 2

If positional pain pattern and friction rub suggest pericarditis:

• Initiate anti-inflammatory therapy with ibuprofen 600–800 mg three times daily for 1–2 weeks plus colchicine 0.6 mg twice daily for 3 months. 2
• Arrange follow-up echocardiography to assess for pericardial effusion. 2

If esophageal symptoms predominate:

• Initiate an empiric proton-pump inhibitor trial (e.g., omeprazole 20 mg daily). 2
• Refer for upper endoscopy or esophageal function testing if symptoms persist. 2

Critical Pitfalls to Avoid

• Do not dismiss ACS based solely on pleuritic character or chest-wall tenderness; up to 7% of patients with reproducible tenderness still have ACS. 1, 2
• Do not rely on nitroglycerin response to differentiate cardiac from esophageal chest pain, as esophageal spasm also responds. 1, 2
• Do not assume a normal physical examination excludes myocardial infarction; uncomplicated MI can present with entirely normal findings. 1, 2
• Do not attribute symptoms to costochondritis without first obtaining ECG and troponin, especially in a woman with throat discomfort. 1, 2
• Do not accept a negative CT pulmonary angiography as definitive if PE suspicion remains high; V/Q imaging is more sensitive for chronic thromboembolic disease. 3