What should I do for severe pain in the right lower chest wall?

Severe Right Lower Chest Wall Pain: Immediate Evaluation and Management

For severe pain in the right lower chest wall, you must first obtain a 12-lead ECG within 10 minutes and measure high-sensitivity cardiac troponin immediately to exclude acute coronary syndrome, even though the location and reproducibility suggest a musculoskeletal cause. 1

Immediate Life-Threatening Exclusions (First 10 Minutes)

Severe chest pain of any location requires urgent cardiac evaluation before attributing symptoms to benign causes. 2

• Obtain a 12-lead ECG within 10 minutes of presentation, regardless of whether the pain appears musculoskeletal. 1
• Measure high-sensitivity cardiac troponin immediately; it is the most sensitive biomarker for myocardial injury and cannot be skipped based on pain location alone. 1
• Assess vital signs including heart rate, respiratory rate, oxygen saturation, and bilateral arm blood pressures to detect signs of pulmonary embolism (tachycardia >100 bpm occurs in >90% of PE patients) or aortic dissection (blood pressure differential >20 mmHg between arms). 1
• Perform a focused cardiovascular examination for new murmurs, pericardial friction rub, unilateral absent breath sounds (pneumothorax), or signs of hemodynamic instability. 1

Critical Cardiac Considerations

• Approximately 13% of patients with sharp or pleuritic-type chest pain still have acute myocardial ischemia, so pain character alone does not exclude acute coronary syndrome. 1
• A completely normal physical examination does not exclude uncomplicated myocardial infarction. 1
• Right-sided chest pain can represent atypical presentations of acute coronary syndrome, particularly in women, elderly patients, or those with diabetes. 1

Other Life-Threatening Causes to Exclude

• Pulmonary embolism: Acute dyspnea with pleuritic chest pain, tachycardia (>90% of cases), and tachypnea are hallmark features. 1
• Pneumothorax: Unilateral absence or marked reduction of breath sounds with hyperresonant percussion; tension physiology causes hemodynamic instability. 1
• Pneumonia: Fever with localized pleuritic pain, regional dullness to percussion, and egophony suggest this diagnosis. 1

Most Likely Diagnosis: Costochondritis/Chest Wall Syndrome

Once life-threatening causes are excluded, costochondritis accounts for approximately 43% of chest pain presentations in primary care settings. 1, 3

Diagnostic Features Supporting Musculoskeletal Origin

• Pain reproducible by palpation of the chest wall or costochondral joints is the hallmark finding. 3
• Pain that worsens with breathing, turning, twisting, bending, or arm movement strongly suggests musculoskeletal origin. 1, 3
• Pain localized to a very limited area provides the highest diagnostic information against angina. 3
• Sharp, stabbing quality that varies with position or respiration is characteristic. 3
• Tenderness at specific costochondral junctions confirms costochondritis or Tietze syndrome. 3

Clinical Presentation Patterns

• Pain is often localized retrosternally (52%) or on the left side (69%), but right-sided presentation occurs in approximately 31% of cases. 4
• In 28% of patients, pain is persistent rather than intermittent. 4
• Most patients (72%) report no specific temporal association of pain. 4
• Approximately 55% of patients still have chest pain after 6 months, indicating a chronic course. 4

Management Algorithm

If ECG Shows ST-Elevation or New Ischemic Changes OR Troponin Is Elevated

• Activate emergency medical services immediately and transport to the emergency department. 1
• Administer aspirin 162-325 mg. 5
• Place on cardiac monitor. 5
• Manage as acute coronary syndrome. 1

If ECG and Initial Troponin Are Normal

• Repeat troponin at 3-6 hours to definitively exclude myocardial injury (up to 5% of ACS patients have a normal initial ECG). 1
• Attempt pain reproduction with palpation of the chest wall and costochondral junctions. 1
• Assess whether pain worsens with arm movement, deep breathing, or torso rotation. 3

If Both Troponins Are Normal and Pain Is Reproducible

Diagnose costochondritis and initiate treatment:

• Prescribe NSAIDs: ibuprofen 600-800 mg three times daily for 1-2 weeks or naproxen at appropriate doses. 1, 6
• Advise temporary avoidance of movements that aggravate chest wall pain. 1
• Provide reassurance that the condition is benign. 1
• Arrange outpatient follow-up if symptoms persist beyond 2 weeks. 3

Important NSAID safety considerations: NSAIDs increase the risk of heart attack or stroke with longer use, should be used at the lowest effective dose for the shortest time needed, and can cause gastrointestinal ulcers and bleeding. 6

Critical Pitfalls to Avoid

• Do not assume reproducible chest wall tenderness rules out acute coronary syndrome; up to 7% of patients with palpation-induced tenderness still have ACS. 1
• Do not rely on nitroglycerin response to differentiate cardiac from non-cardiac chest pain, as esophageal spasm and other conditions may also respond. 1
• Do not dismiss cardiac causes solely because pain is right-sided or sharp; atypical presentations are common in women, elderly patients, and those with diabetes. 1
• Do not skip troponin testing based on clinical impression alone; musculoskeletal findings are reassuring but cardiac problems still account for 10-34% of episodes even when musculoskeletal features are present. 3
• Do not delay transfer to the emergency department for troponin testing in office settings if high-risk features are present (hemodynamic instability, diaphoresis, dyspnea, nausea, syncope, or age >75 years with accompanying symptoms). 5

When to Seek Emergency Care Immediately

Transport urgently to the emergency department by EMS if any of the following are present: 3

• Chest pain accompanied by diaphoresis, nausea, vomiting, or cold sweats
• Symptoms that interrupt normal activity
• Associated dyspnea, tachycardia, or hypotension
• Radiation to the arm, jaw, neck, or back
• New ECG abnormalities
• Elevated cardiac troponin

Special Considerations for Persistent or Recurrent Pain

• Document radiographic resolution with repeat chest radiography six weeks after initial treatment in patients with persistent symptoms, smokers, or those older than 50 years to exclude underlying pneumonia or malignancy. 7
• Consider alternative diagnoses such as herpes zoster (unilateral dermatomal pain that may precede rash by days) if pain follows a dermatomal distribution. 1, 5
• Evaluate for pulmonary causes if fever, productive cough, or dyspnea develop. 8, 9