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Differential diagnosis for pleuritic chest pain

Common and important causes of pleuritic chest pain for doctors and medical students

Pleuritic chest pain refers to pain felt worse on inspiration. It usually occurs due to visceral and parietal pleura rubbing over each other but can be due to musculoskeletal or nerve-related pathology.

Pleurisy (due to pneumonia)Suggested by: being worse on inspiration, shallow breaths, pleural rub, evidence of infection (fever, cough, consolidation, etc.).
Confirmed by: opacification in lung periphery on CXR and sputum/blood culture
Pulmonary infarct (due to embolus arising from DVT in leg, silent pelvic vein thrombosis, silent right atrial thrombosis)Suggested by: sudden onset shortness of breath, pleural rub, cyanosis, tachycardia, loud P2, associated DVT, or risk factors such as recent surgery, cancer, immobility.
Confirmed by: V/Q scan mismatch, CTPA showing clot in pulmonary artery
PneumothoraxSuggested by: pain in centre or side of chest with abrupt breathlessness. Diminished breath sounds, resonance to percussion over site.
Confirmed by: expiratory CXR showing loss of lung markings outside sharp pleural line.
Pericarditis (caused by MI, infection, especially viral, malignancy, uraemia, connective tissue diseases)Suggested by: sharp pain worse lying flat or with trunk movement, relieved by leaning forward. Pericardial rub.
Confirmed by: ECG showing diffuse concave ST elevation and PR depression.
CXR: globular heart shadow and relief with pericardial drainage (if hypotensive).
Musculoskeletal injury or inflammationSuggested by: associated focal tenderness. Often history of trauma.
Confirmed by: excluding other explanations. Normal troponin.
Chest wall pain (e.g. chostochondritis or Tietze’s syndrome, strained muscle or rib injury)Suggested by: chest pain and localised tenderness of chest wall or chest pain on twisting of neck or thoracic cage.
Confirmed by: no raised troponin after 12 hours, and no ST-segment or T-wave changes serially on ECG. Response to rest and analgesics.
Referred cervical root painSuggested by: Previous minor episodes, exacerbation by neck movement (producing closure of nerve root foramina related to area of pain).
Confirmed by: clinical features and MRI scan.
ShinglesSuggested by: pain (often burning) in a dermatomal distribution, previous exposure to chicken pox or shingles attacks. More common in immunocompromised patients.
Confirmed by: vesicles appearing within days.

Related page: retrosternal chest pain

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