Makindo Medical Notes

Pain on inspiration, also called pleuritic chest pain, refers to sharp, stabbing pain that worsens when the patient inhales. It is a symptom, not a diagnosis, and often points to irritation of the parietal pleura, pericardium, or chest wall structures. Recognising pleuritic pain is important, as causes range from benign musculoskeletal strain to life-threatening conditions such as pulmonary embolism.

🧬 Pathophysiology

• Parietal pleura: Richly innervated by intercostal and phrenic nerves. Inflammation (pleuritis, infection, infarction) stimulates pain fibres, producing sharp inspiratory pain.
• Pericardium: Pericarditis can mimic pleuritic pain as the inflamed pericardial surfaces rub during respiratory movement.
• Chest wall & musculoskeletal pain: Intercostal muscle strain or rib fractures cause pain accentuated by deep breaths or coughing.
• Diaphragmatic irritation: Subdiaphragmatic processes (liver abscess, splenic infarct, subphrenic abscess) refer pain to the shoulder (phrenic nerve).

⚠️ Common Causes

• 🫁 Respiratory: Pneumonia, pulmonary embolism (PE), pleuritis, pneumothorax, TB, lung cancer.
• ❤️ Cardiac/Pericardial: Pericarditis, post-MI pericarditis (Dressler’s), myocardial infarction (can occasionally present as pleuritic pain).
• 🦴 Musculoskeletal: Costochondritis, intercostal muscle strain, rib fracture, trauma.
• 🧪 Gastrointestinal/Abdominal: Subdiaphragmatic abscess, cholecystitis, pancreatitis, splenic infarct.
• 🦠 Other: Autoimmune (SLE, RA-associated pleuritis), post-surgical or post-radiation chest pain.

🩺 History & Examination

• Character: Sharp, stabbing pain worse on inspiration, coughing, or sneezing.
• Location: Localised (pleuritis) or diffuse (musculoskeletal strain).
• Associated symptoms: Dyspnoea, cough, haemoptysis, fever, calf pain/swelling (PE), palpitations.
• Risk factors: Smoking, recent surgery/immobilisation, OCP use, trauma.
• Examination:
  • Respiratory: reduced air entry, bronchial breathing, crackles, pleural rub.
  • CV: pericardial rub, tachycardia, hypotension.
  • MSK: localised tenderness, reproducible with palpation/movement.

🔎 Investigations

• Bloods: FBC, CRP/ESR, D-dimer (if PE suspected), troponin (if cardiac cause suspected).
• CXR: Look for consolidation, effusion, pneumothorax.
• ECG: Pericarditis (saddle-shaped ST elevation), MI, arrhythmias.
• CT pulmonary angiogram (CTPA): Gold standard for PE.
• Ultrasound: Useful for pleural effusion, pericardial effusion, subphrenic collections.
• Echocardiogram: Assess pericardial disease or cardiac function.

🚩 Red Flags

• Sudden onset severe chest pain + dyspnoea → consider PE or pneumothorax.
• Haemodynamic instability (hypotension, tachycardia).
• Hypoxia or raised respiratory rate.
• Haemoptysis.
• Persistent fever, weight loss, night sweats (TB, malignancy).

🛠️ Management Principles

• 🎯 Treat underlying cause:
  • Pneumonia → antibiotics, oxygen, fluids.
  • PE → anticoagulation, thrombolysis if massive PE.
  • Pneumothorax → aspiration or chest drain depending on size/symptoms.
  • Pericarditis → NSAIDs ± colchicine; treat underlying cause.
  • Musculoskeletal pain → NSAIDs, rest, physiotherapy.
• 💊 Analgesia: NSAIDs often effective for pleuritic pain; opioids if severe.
• 🧴 Supportive: Oxygen if hypoxic, fluids if septic, physiotherapy if atelectasis present.
• 📣 Escalation: Admit if red flags, uncertain diagnosis, or severe cardiorespiratory compromise.

📚 Summary Table

Cause	Key Tests	Management
Pulmonary Embolism	D-dimer, CTPA, Doppler legs	Anticoagulation (LMWH, DOAC), thrombolysis if massive
Pneumonia	CXR, FBC, sputum culture	Antibiotics, oxygen, fluids
Pneumothorax	CXR, ABG	Observation if small/asymptomatic; aspiration or chest drain if large/symptomatic
Pericarditis	ECG, echo, CRP	NSAIDs + colchicine, treat underlying cause
Costochondritis/MSK	Clinical diagnosis (tenderness on palpation)	NSAIDs, reassurance, physiotherapy
Subdiaphragmatic abscess	USS/CT abdomen	IV antibiotics, surgical/radiological drainage

📝 Take-Home Message

Pain on inspiration (pleuritic chest pain) most often reflects pleural, pericardial, or chest wall pathology. Always rule out life-threatening causes (PE, pneumothorax, pneumonia, pericarditis) before attributing to benign musculoskeletal pain. A structured history, focused examination, and targeted investigations guide safe management.