Pleuritic chest pain is typically sharp and worse on inspiration due to irritation of the parietal pleura, which is richly innervated by intercostal nerves. The key clinical task is distinguishing benign inflammatory causes from life-threatening pathology (PE, pneumothorax, MI, aortic dissection).

📍 Location: Exact site (lateral chest wall suggests pleura; retrosternal may suggest cardiac). Radiation to back → consider aortic pathology.
⏱️ Onset & Duration:
- Sudden onset → PE, pneumothorax, dissection
- Gradual onset → infection or inflammatory causes
🔪 Character: Sharp, stabbing pain worse with deep breathing, coughing, or movement suggests pleural irritation.
🤒 Associated Symptoms:
- Fever, productive cough → pneumonia
- Acute dyspnoea, haemoptysis → PE
- Trauma → rib fracture or pneumothorax
- Orthopnoea, palpitations → cardiac cause
- Calf pain, recent immobility, cancer → PE risk factors
📉 Aggravating/Relieving Factors:
- Worse on inspiration → pleural pathology
- Improves sitting forward → pericarditis
- Reproducible on palpation → musculoskeletal
📚 Past Medical History:
- Previous VTE, recent surgery, malignancy
- Autoimmune disease (pleuritis, pericarditis)
- COPD or asthma

🧠 Red Flag Diagnoses Not to Miss

🫁 Pulmonary embolism
💨 Pneumothorax (especially tension)
❤️ Acute coronary syndrome
🩸 Aortic dissection
🫀 Pericarditis with effusion/tamponade

📊 Common Causes — Investigations & Management

Cause	Key Tests	Management
🔥 Pleuritis	CXR, inflammatory markers (CRP), autoimmune screen if recurrent	NSAIDs, treat underlying infection or autoimmune cause
💨 Pneumothorax	CXR (expiratory if needed), bedside ultrasound	Oxygen, needle aspiration or chest drain depending on size & stability
🫁 Pulmonary Embolism	Wells score → D-dimer → CTPA	Anticoagulation (DOAC/LMWH), thrombolysis if massive PE
🦴 Rib Fracture	Clinical ± CXR	Analgesia, incentive spirometry to prevent atelectasis
🫀 Pericarditis	ECG (diffuse ST elevation), troponin, echo	NSAIDs + colchicine; treat underlying cause
🦠 Pneumonia	CXR, bloods, sputum culture	Antibiotics per local guidelines, oxygen if hypoxic

🔍 Physical Examination

👀 General Inspection: Respiratory distress, tachypnoea, cyanosis.
🫁 Chest Examination:
- Auscultation: crackles (pneumonia), pleural rub, reduced breath sounds (effusion/pneumothorax)
- Percussion: dullness (effusion), hyperresonance (pneumothorax)
- Palpation: reproducible tenderness (MSK cause)
❤️ Cardiovascular: New murmur, pericardial rub, arrhythmia, unequal pulses (dissection).
🦵 Peripheral Signs: Calf swelling or tenderness (DVT).

🧪 Core Investigations

📸 Chest X-ray: Pneumonia, effusion, pneumothorax.
📈 ECG: Exclude ACS, pericarditis, right heart strain (PE).
🧬 Blood Tests:
- FBC, CRP
- D-dimer (if PE probability low/intermediate)
- Troponin (if cardiac suspicion)
🖥️ CTPA: Gold standard for PE diagnosis.
🫀 Echocardiography: If pericardial effusion suspected.

🌬️ Causes of Pain on Inspiration

🫁 Pulmonary: Pleuritis, pneumonia, PE, pneumothorax
❤️ Cardiovascular: Pericarditis, MI, aortic dissection
🦴 Musculoskeletal: Costochondritis, rib fracture, thoracic strain
🍽️ Gastrointestinal: GERD, hiatal hernia, subdiaphragmatic abscess

💊 Management Principles

Stabilise ABCs if unstable.
Treat the underlying cause promptly.
Provide adequate analgesia (NSAIDs first-line for pleuritic inflammation).
Anticoagulate confirmed PE unless contraindicated.
Escalate urgently for red flag diagnoses.

⚖️ Always risk-stratify early. In acute pleuritic chest pain, the priority is excluding life-threatening pathology before attributing symptoms to benign musculoskeletal or viral causes.

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Clinical History Pleuritic Chest Pain 🩺