Pleuritic Chest Pain

Pleuritic Chest Pain is pain that hurts every time the patient takes a breath or coughs. It can be a sign of serious lung diseases, no-so-serious ones, or mild conditions which have nothing to do with the lung at all. A major clue, as we’ll note, is whether the pain is also felt with twisting, stretching, or pushing on the chest. In those cases, it’s not the lung.

Causes of Pleuritic Chest Pain

xxMay Be Imminently Life-ThreateningxxxxNot Imminently Life-Threatening
** Pneumonia
** Pneumothorax
** Pleural Effusion
** Pulmonary Embolism
** Pericarditis
** Pleurisy / Pleuritis
** Lung Cancer
** Rib Fracture (without trauma)
** Chest Wall Pain (e.g. muscle strain)
** Anxiety

We order a Chest X-ray (CXR) for Pleuritic Chest Pain in the following cases (it’s easy to see the following diseases):

1.  Fever or Drenching Sweats: Maybe Pneumonia

2.  Shortness of BreathPneumothorax, Pleural Effusion, Pneumonia, Pulmonary Embolism (PE)  (The CXR is often normal with a PE, see “Special Cases, no. 4” at end)

  • Significant “True” Shortness of Breath always gets worse with exertion; otherwise, it’s just a feeling or sensation, but not a sign of heart / lung disease. See link for explanation.

3.  Abnormal Lung Exam with stethoscope:  May find signs suggesting lung disease

4.  Coughing up Bloody Phlegm:  Could be Pneumonia, Pulmonary Embolism, Lung Cancer

5.  Elderly / Immunocompromised: we’re more likely to get x-rays for such patients with new symptoms

We DON’T need a CXR if none of the above, especially not if:

  • Chest pain also hurts with certain twisting or stretching movements, or with pressing on the chest (likely Muscle Strain, commonly occurs from coughing)
  • Chest pain comes & goes, does not occur with every deep breath:ย  Likely Muscle Strain or Anxiety

If EVERYTHING IS NORMAL  —  Diagnose Pleurisy (non-serious viral infection) if:

  • No shortness of breath
  • Normal examination
  • Normal CXR (if obtained)

SPECIAL CASES (1-3 are Uncommon)

1.  Pain hurts in one particular spot over a rib, particularly with tapping it.  Needs Rib X-ray to rule out Rib Fracture without trauma (from bone diseases like metastatic cancer)

2.  Pain feels lots better leaning forward.  Needs EKG to rule out Pericarditis.

3.  Seems like Pleurisy, but we might think Pleuritis (from diseases like Lupus) if:

  • Previous episodes
  • Other Lupus symptoms: joint pains, cheekbone rash, other unusual rashes, spotty hair loss, mouth ulcers.
  • If suggestive, we order an ANA blood test.

4.  Seems like Pleurisy, but patient has Risk Factors for Pulmonary Embolism

See Pleuritic Chest Pain — Full Text for more in-depth explanations and discussions.

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