II. Definitions

  1. Pleuritic Chest Pain (Symptom)
    1. Chest Pain exacerbated by forceful breathing
  2. Pleurisy
    1. Inflammation of parietal pleura
    2. One of many conditions resulting in Pleuritic Pain

III. Pathophysiology

  1. Parietal pleura (not visceral) has Sensory Nerves
    1. Irritated by inflammation or Trauma
  2. Nerve distribution
    1. Intercostal nerves referred to associated Dermatomes
      1. Rib Cage
      2. Lateral hemidiaphragm
    2. Phrenic nerve referred to ipsilateral neck, Shoulder
      1. Central hemidiaphragm

IV. Causes: Serious and life-threatening

  1. Pulmonary Embolism (represents 5-20% of Pleurisy in ER)
  2. Pneumothorax or spontaneous Pneumomediastinum
  3. Pneumonia
  4. Pericarditis
  5. Myocarditis
  6. Myocardial Infarction (Pleuritic Pain is atypical)
  7. Aortic Dissection

V. Causes: Infection

VI. Causes: Other

  1. Musculoskeletal Causes
    1. Musculoskeletal Chest Pain
    2. Cough fracture
  2. Cardiopulmonary Causes
    1. Post-Myocardial Infarction, Cardiac injury, surgery
    2. Asbestosis
  3. Hematologic and oncologic conditions
    1. Malignancy (esp. malignant Pleural Effusion)
    2. Familial Mediterranean Fever (recurrent episodes)
    3. Sickle Cell Anemia (acute Sickle Cell Crisis)
  4. Inflammatory Conditions
    1. Reactive Eosinophilic pleuritis
    2. Rheumatologic pleuritis (Systemic Lupus, Rheumatoid Arthritis)
    3. Sjogren Syndrome
    4. Ankylosing Spodylitis
  5. Gastrointestinal and Genitourinary Conditions
    1. Inflammatory Bowel Disease
    2. Pancreatitis
    3. Chronic Renal Failure

VII. Symptoms

  1. Sudden and intense, sharp, stabbing or burning Chest Pain on forceful breathing
  2. Perceived Dyspnea (due to suppressed respirations)
  3. Provocative factors
    1. Movement
    2. Forceful breathing
      1. Deep breathing
      2. Coughing
      3. Sneezing
      4. Laughing
  4. Radiation
    1. May radiate to neck or Shoulder (via phrenic nerve) when diaphragm is involved
    2. Radiation to arms (especially both arms or right arm) is more suggestive of Acute Coronary Syndrome
    3. Radiation to intrathoracic back (severe intensity) may be seen with Aortic Dissection, Pancreatitis

VIII. Symptoms: Red flags for serious or atypical causes

  1. Sudden, acute onset within minutes (consider life-threatening causes listed above)
  2. Significant Dyspnea (Pulmonary Embolism, Pneumothorax, Pneumonia)
  3. Night Sweats
  4. Significant weight loss
  5. Joint Pain
  6. Syncope
  7. Productive cough

IX. Signs: Red Flags on cardiopulmonary exam

  1. Hypotension
  2. Tachycardia
  3. Tachypnea
  4. Pericardial Friction Rub
  5. Rales, asymmetric or absent lung sounds

X. Labs

  1. Consider D-Dimer
  2. Consider cardiac enzymes

XI. Diagnostic Tests

  1. Chest XRay (obtain in all patients)
    1. Widened mediastinum (Aortic Dissection)
    2. Pneumothorax
    3. Pleural Effusion
    4. Pneumonia
  2. Electrocardiogram
    1. Acute Coronary Syndrome
      1. See Electrocardiogram in Myocardial Infarction
      2. ST Segment changes
      3. New Q Waves or new onset Left Bundle Branch Block
      4. T Wave Inversion
    2. Pulmonary Embolism
      1. See Electrocardiogram in Pulmonary Embolism
      2. Electrocardiogram shows nonspecific changes in 80% of cases
      3. Classic Findings (Right heart strain): S1 Q3 T3 (seen in under 20% of cases)
      4. T Wave Inversion especially in anteroseptal (v1-v4) and possibly inferior (II, III, aVF) leads
    3. Pericarditis
      1. See Electrocardiogram in Pericarditis
      2. Abnormal EKG changes in 90% of Pericarditis cases
      3. PR Segment Depression (without T Wave Inversion)
      4. Diffuse concave upward ST Segment Elevation

XII. Management

  1. NSAIDs for analgesia (preferred over Narcotics)
    1. Indomethacin 50-100 mg orally three times daily with food or milk
    2. Corticosteroids (Prednisone) may be considered in patients unable to take NSAIDS
  2. Identify cause
    1. Evaluate first for serious causes
    2. Consider Medication Causes of Pleural Disease

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Related Studies

Ontology: Pleurisy (C0032231)

Definition (CHV) inflammation of the lining of the lung (pleura)
Definition (CHV) inflammation of the lining of the lung (pleura)
Definition (CHV) inflammation of the lining of the lung (pleura)
Definition (MSHCZE) ZÁNĚT PLEURA (pohrudnice), blány (membrány) pokrývající plíce. Je-li rozšířen na pleura parietalis, pociťuje se bolest v oblasti hrudníku (HRUDNÍK – BOLEST). R
Definition (NCI) Inflammation of the pleura. It is usually caused by infections. Chest pain while breathing or coughing is the presenting symptom.
Definition (CSP) inflammation of the pleura, with exudation into its cavity and upon its surface; may occur as either an acute or a chronic process.
Definition (MSH) INFLAMMATION of PLEURA, the lining of the LUNG. When PARIETAL PLEURA is involved, there is pleuritic CHEST PAIN.
Concepts Disease or Syndrome (T047)
MSH D010998
ICD9 511
ICD10 R09.1
SnomedCT 32203001, 266406002, 196075003
English Pleurisies, PLEURISY, PLEURITIS, pleurisy, pleurisy (diagnosis), Pleurisy [Disease/Finding], pleurisies, pleuritis, Inflammation of pleura, Pleurisy (excl TB), Pleurisy (disorder), Pleurisy, NOS, Pleuritis, NOS, Pleurisy (disorder) [Ambiguous], Pleurisy, Pleurisy NOS, Pleuritis, Pleuritides, Pleurisy (excluding TB)
French PLEURESIE, Pleurite, Pleurésie (excl TB), PLEURITE, Pleurésie
Portuguese PLEURISIA, Pleurisia (excl.TB), PLEURITE, Pleuris, Pleurite, Pleuresia, Pleurisia
Spanish PLEURESIA, Pleuresía (excl TB), Pleuritis, PLEURITIS, pleuresía, pleuritis (concepto no activo), pleuritis (trastorno), pleuritis, Pleuresía, Pleuresia
German PLEURITIS, Pleuritis (ausser TB), RIPPENFELLENTZUENDUNG, Pleuritis, Brustfellentzündung
Dutch pleuritis, pleuritis (excl. TBC), pleura-ontsteking, Pleuritis
Italian Pleurite (tubercolare esclusa), Pleurite
Japanese 胸膜炎(結核性を除く), キョウマクエン, キョウマクエンケッカクセイヲノゾク, 胸膜炎, 肋膜炎
Swedish Lungsäcksinflammation
Czech zánět pohrudnice, pleuritida, pleura - zánět, Pleuritida (mimo TBC), Zánět pohrudnice, Pleuritida
Finnish Keuhkopussitulehdus
Korean 늑막염
Polish Zapalenie opłucnej
Hungarian Mellhártyagyulladás, Pleuritis (kivéve TBC), Pleuritis
Norwegian Pleuritt, Plevritt, Lungehinnebetennelse

Ontology: Chest pain on breathing (C0423729)

Concepts Sign or Symptom (T184)
ICD9 786.52
ICD10 R07.1
SnomedCT 309552003, 207082006, 75483001, 158395001, 274664007
English Painful respiration NOS, [D]Painful respiration NOS, [D]Painful respiration (context-dependent category), [D]Painful respiration NOS (context-dependent category), Painful respiration [D], Painful respiratory movement, painful respirations were observed, painful respiration, painful respiration (physical finding), breathing pains, pain breathing, Pain;breathing, Pain;respiratory;chest, breath chest pains, painful breath, breath pain, breathing chest pain, breaths painful, pain respiratory, chest breathing pain, Pain;respiration, Pain;respiratory, pain respiration, pain respirations, respiration pain, breathing painful, chest pain breathing, pain chest breathing, breath chest pain, breathing pain, breathing chest pains, [D]Painful respiration (situation), [D]Painful respiration NOS (situation), [D]Painful respiration, Breathing painful (situation), Painful respiration, Breathing painful, Chest pain on breathing, Breathing painful (finding), Chest pain on breathing (finding), chest; pain, on breathing, pain; chest, on breathing, pain; respiration, painful; respiratory, respiration; painful, respiration; pain, Painful respiration [D] (finding), pain during respiration, painful breathing, respiratory chest pain, respiratory pain
Italian Respirazione dolorosa
Japanese 呼吸時疼痛, コキュウジトウツウ
Spanish [D]respiración dolorosa (categoría dependiente del contexto), [D]respiración dolorosa, SAI (categoría dependiente del contexto), [D]respiración dolorosa (situación), [D]respiración dolorosa, SAI (situación), [D]respiración dolorosa, SAI, [D]dolor al respirar, SAI, [D]respiración dolorosa, dolor de pecho al respirar, dolor torácico al respirar (hallazgo), dolor torácico al respirar, movimiento respiratorio doloroso, respiración dolorosa (hallazgo), respiración dolorosa [D] (hallazgo), respiración dolorosa [D], respiración dolorosa, Respiración dolorosa
German Brustschmerzen bei der Atmung, schmerzhafte Atmung
Czech Bolestivá respirace
Korean 숨쉴때의 가슴통증
Hungarian Fájdalmas légzés
Dutch ademhaling; pijnlijk, ademhaling; pijn, borst; pijn, bij ademhaling, pijn; ademhaling, pijn; borst, bij ademhaling, pijnlijk; ademhaling, Pijn op borst bij ademhaling, pijnlijke ademhaling
Portuguese Respiração dolorosa
French Respiration douloureuse