Pain on inspiration

Medicine > Cardiovascular

Differential Diagnosis Schema 🧠

Respiratory Causes

Pulmonary embolism: Sudden onset pleuritic chest pain, dyspnoea, tachycardia, risk factors like recent surgery, immobility.
Pneumonia: Pleuritic chest pain, fever, productive cough, crackles on auscultation.
Pneumothorax: Sharp, unilateral pleuritic pain, reduced breath sounds on the affected side, hyperresonance on percussion.
Pleuritis (pleurisy): Pleuritic chest pain, often viral or secondary to a known respiratory condition like pneumonia or pulmonary embolism.
Pleural effusion: Dull, pleuritic pain, decreased breath sounds, and dullness to percussion over the effusion.
Lung cancer: Pleuritic pain, haemoptysis, weight loss, chronic cough.

Cardiovascular Causes

Pericarditis: Pleuritic chest pain that improves when sitting forward, pericardial friction rub, diffuse ST elevation on ECG.
Myocardial infarction: Often presents with central chest pain, but may have a pleuritic component if infarction is near the pleura.
Aortic dissection: Sudden, severe chest pain radiating to the back, may present with pleuritic pain if pleura is involved, hypertension, pulse discrepancies.
Pulmonary hypertension: May cause pleuritic chest pain, dyspnoea, signs of right heart failure.

Gastrointestinal Causes

Oesophageal rupture (Boerhaave syndrome): Sudden, severe chest pain, associated with vomiting, subcutaneous emphysema.
Gastroesophageal reflux disease (GORD): Burning chest pain that may mimic pleuritic pain, often related to meals, relieved by antacids.
Cholecystitis: Right upper quadrant pain that can radiate to the right shoulder or chest, often postprandial, fever, Murphy’s sign positive.

Musculoskeletal Causes

Costochondritis: localized chest wall pain, worse with palpation, no systemic signs
Rib fracture: sharp, localized chest pain exacerbated by inspiration, history of trauma, crepitus on palpation
Muscle strain: diffuse or localized pain following overuse or injury, worse with movement and deep inspiration

Key Points in History 🥼

Presenting Symptoms

Onset and duration: sudden onset (suggests pulmonary embolism, pneumothorax) versus gradual onset (may suggest pneumonia, pleuritis)
Character: sharp (often pleuritic), crushing (cardiac), burning (GERD)
Location: unilateral (pneumothorax, pleuritis) versus central (MI, GERD)
Associated symptoms: dyspnea, cough, fever (suggests infection); nausea, vomiting (GERD, MI); recent trauma (rib fracture)
Relieving and exacerbating factors: pain worse on inspiration (pleuritic causes); relieved by sitting forward (pericarditis); worsened by movement (musculoskeletal)
Risk factors: recent surgery, immobilization (pulmonary embolism); smoking, COPD (pneumothorax); viral illness (pleuritis)
Previous episodes: history of similar pain may suggest a chronic condition (e.g., GERD, pericarditis)

Background

Past Medical History: relevant conditions include asthma, COPD, heart disease, recent surgery, trauma
Drug History: anticoagulants (risk of hemothorax), recent medication changes
Family History: hereditary conditions such as clotting disorders (increased risk of pulmonary embolism)
Social History: smoking (COPD, lung cancer), occupational exposure (asbestos), recent travel (pulmonary embolism risk)
Lifestyle factors: alcohol use (risk of trauma), physical activity level (risk of musculoskeletal injury)

Possible Investigations 🌡️

Blood Tests

Full Blood Count (FBC): assess for infection (raised WBC in pneumonia) or anemia (possible GI bleed)
D-dimer: useful in ruling out pulmonary embolism in low-risk patients
Troponin: elevated in myocardial infarction
Arterial Blood Gas (ABG): assess for hypoxia, hypercapnia, and acid-base disturbances, particularly in suspected PE or pneumothorax
Liver function tests (LFTs) and amylase: if gallbladder or pancreatic disease is suspected
Cardiac enzymes: if a cardiac cause is suspected

Imaging

Chest X-ray: first-line imaging to assess for pneumothorax, pneumonia, pleural effusion, rib fractures
CT Pulmonary Angiography (CTPA): gold standard for diagnosing pulmonary embolism
Echocardiogram: assess for pericarditis, pericardial effusion, or other cardiac causes
Abdominal ultrasound or CT: if cholecystitis, pancreatitis, or other abdominal pathology is suspected
ECG: essential in ruling out cardiac causes, such as myocardial infarction or pericarditis
MRI: considered if more detailed imaging of the chest wall or heart is needed

Specialist Tests

V/Q Scan: alternative to CTPA in diagnosing pulmonary embolism, particularly in patients with contraindications to contrast
Stress Testing: may be indicated if there is a suspicion of ischemic heart disease as the cause of pain
Endoscopy: considered if esophageal rupture or GERD is strongly suspected
Pleural fluid analysis: if pleural effusion is detected, fluid can be aspirated and analyzed for infection, malignancy, or other causes

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