Pleuritic Chest Pain

Differential Overview

❑ Costochondritis

❑ Pneumonia

❑ Rib fracture

❑ Pulmonary embolism

❑ Pleurisy

❑ Pneumothorax

❑ Pericarditis

❑ Lung cancer

❑ Pneumomediastinum

❑ Splenic infarction

Diagnostic Approach

Pleuritic chest pain, intensified by a deep breath, usually has a pulmonary or chest wall origin. Cardiac pain is almost never pleuritic (LR 0.2), sharp or stabbing (LR 0.3), positional (LR 0.3) or reproduced by palpation (LR 0.3).

Clinical Findings

Costochondritis  Pain is localized over the costochondral junctions, which will be exquisitely tender with palpation.

Pneumonia  Pleuritic pain, fever, and cough that produces colored sputum are the hallmarks of pneumonia.

Rib fracture  Pain is usually preceded by a history of chest wall trauma or malignancy, although vigorous cough may precipitate it. There is exquisite tenderness focally over a rib.

Pulmonary embolism  High suspicion must be maintained for pulmonary embolism. Pleuritic pain occurs in only 10% of cases of pulmonary embolism, and when present, suggests pulmonary infarction. Look for associated signs of acute dyspnea, hemoptysis, and an embolic source (e.g., leg swelling). The Pulmonary Embolism (PE) Rule: 3 points each for clinical signs of DVT (swelling/tenderness) or an alternate diagnoses less likely than PE. 1.5 points each for HR .100, immobilization .2 days, surgery during the prior 4 weeks or prior DVT or PE. 1 point each for hemoptysis or cancer within 6 months.

Pleurisy  Pain is worsened by deep inspiration or cough but is not affected by palpation. There is often a friction rub and low-grade fever. This may be caused by bacterial pneumonia or primary viral infection (e.g., coxsackievirus), pulmonary infarction, neoplasm, uremia, or connective tissue disease (lupus).

Pneumothorax  Acute pleuritic chest pain and dyspnea are the principal symptoms. With a large pneumothorax, there may be unilateral diminished or distant breath sounds, increased tympany, and decreased chest movement on the affected side. It commonly occurs in a young asthenic patient or in one with emphysema. A tension pneumothorax produces rapidly developing shock with chest tympany and a tracheal shift.

Pericarditis  Pain is usually sharp and pleuritic, increased with twisting, coughing, breathing deeply, swallowing, and lying supine. It is characteristically relieved by sitting up and leaning forward. A two-component or three-component friction rub with a to-and-fro cadence is a key finding. Inflammation of the diaphragmatic pleura may cause radiation to the trapezius, costal margin, or shoulder. Inflammation may arise from underlying causes such as a recent myocardial infarction, viral infection, uremia, tuberculosis, or connective tissue disease. Noninflammatory causes such as uremia may progress to tamponade with little pain.

Lung cancer  Pain occurs when there is pleural involvement and is often accompanied by a unilateral effusion, marked by dullness to percussion.

Pneumomediastinum  It presents with a retrosternal “crunch” on exam, central chest pain, and dyspnea.

Splenic infarction  Low left anterior chest pain and a friction rub occur in a patient with a central embolic source, such as endocarditis or atrial fibrillation.

Pictures

Book Source Details

• Book Title: Field Guide to Bedside Diagnosis
• Author(s): David S. Smith
• Year of Publication: 2007
• Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Field Guide to Bedside Diagnosis, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Field Guide to Bedside Diagnosis Authors: David S. Smith Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-78178-165-5

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