Pleuritic Chest Pain

1. Overview

Pleuritic chest pain is sharp, stabbing or burning chest pain that is worse on deep inspiration, coughing, sneezing or movement. It usually reflects irritation of the parietal pleura, chest wall or adjacent structures.

In an OSCE, the main task is to identify red flags and separate serious causes such as pulmonary embolism, pneumothorax and pneumonia from less dangerous causes such as viral pleurisy or musculoskeletal chest wall pain.

Key OSCE priorities

• Assess severity immediately.
• Ask about onset, site, radiation and relation to breathing.
• Ask about breathlessness, cough, fever, haemoptysis and collapse.
• Screen for pulmonary embolism risk factors.
• Screen for pneumothorax features.
• Screen for pneumonia and sepsis features.
• Consider cardiac causes including ACS and pericarditis.
• Check observations and oxygen saturation early.
• Perform respiratory and cardiovascular examination.
• Arrange ECG and chest X-ray early in most acute presentations.

Important causes

• Pulmonary embolism.
• Pneumothorax.
• Pneumonia.
• Viral pleurisy.
• Musculoskeletal chest wall pain.
• Rib fracture or trauma.
• Pericarditis.
• Acute coronary syndrome.
• Aortic dissection.
• Pleural effusion.
• Lung cancer or pleural malignancy.
• Tuberculosis.
• Autoimmune pleuritis, such as SLE or rheumatoid disease.

Red flag features

• Sudden severe chest pain.
• Severe shortness of breath.
• Low oxygen saturation.
• Haemoptysis.
• Syncope or collapse.
• Hypotension.
• Tachycardia.
• Cyanosis.
• Fever with sepsis features.
• Unilateral leg swelling.
• Recent surgery or immobility.
• Known cancer.
• Tearing chest pain radiating to the back.
• Abnormal ECG.

2. History Taking

Opening

• Wash hands.
• Introduce yourself.
• Confirm patient identity.
• Explain that you would like to ask about the chest pain.
• Gain consent.
• Check whether the patient is currently in severe pain, very breathless, dizzy or feels faint.
• If acutely unwell, state that you would assess using ABCDE and call for senior help.

Pain history using SOCRATES

• Site: ask where the pain is located.
• Onset: ask when it started and whether it was sudden or gradual.
• Character: ask whether it is sharp, stabbing, burning, tight or tearing.
• Radiation: ask whether it goes to the shoulder, neck, jaw, arm or back.
• Associated symptoms: ask about breathlessness, cough, fever, haemoptysis, palpitations, dizziness and collapse.
• Timing: ask whether it is constant, intermittent or worsening.
• Exacerbating factors: ask whether it is worse on deep breathing, coughing, movement, lying down or exertion.
• Relieving factors: ask whether it improves with rest, leaning forward, analgesia or shallow breathing.
• Severity: ask for a pain score out of 10.

Confirm pleuritic nature

• Ask whether the pain is worse when taking a deep breath.
• Ask whether it is worse when coughing.
• Ask whether it is worse when sneezing or laughing.
• Ask whether movement or twisting worsens the pain.
• Ask whether the pain is reproducible by pressing on the chest wall.
• Ask whether the patient is breathing shallowly because of pain.

Associated respiratory symptoms

• Shortness of breath.
• Cough.
• Sputum production.
• Haemoptysis.
• Wheeze.
• Fever.
• Rigors.
• Night sweats.
• Weight loss.
• Recent viral illness.
• Recurrent chest infections.

Pulmonary embolism screen

• Sudden onset pleuritic chest pain.
• Sudden shortness of breath.
• Haemoptysis.
• Syncope or collapse.
• Unilateral leg swelling or calf pain.
• Recent surgery.
• Recent immobility.
• Long-haul travel.
• Active cancer.
• Previous DVT or PE.
• Pregnancy or postpartum period.
• Combined oral contraceptive pill or oestrogen therapy.
• Known thrombophilia.

Pneumothorax screen

• Sudden unilateral pleuritic chest pain.
• Sudden breathlessness.
• Pain on one side of the chest.
• Tall thin body habitus.
• Smoking.
• Known lung disease such as COPD.
• Recent trauma.
• Recent procedure such as central line insertion or lung biopsy.
• Previous pneumothorax.
• Severe symptoms suggesting tension pneumothorax.

Pneumonia and infection screen

• Fever.
• Rigors.
• Productive cough.
• Purulent sputum.
• Breathlessness.
• Pleuritic pain localised to one side.
• Confusion, especially in older patients.
• Reduced oral intake.
• Recent sick contacts.
• Recent hospital admission.
• Immunosuppression.

Pericarditis screen

• Sharp central chest pain.
• Pain worse lying flat.
• Pain improved by sitting forward.
• Pain radiating to trapezius ridge or shoulder.
• Recent viral illness.
• Fever.
• Palpitations.
• Known autoimmune disease.
• Renal failure.
• Recent myocardial infarction or cardiac procedure.

Acute coronary syndrome screen

• Central crushing or pressure-like chest pain.
• Pain radiating to left arm, jaw, neck or back.
• Pain triggered by exertion.
• Sweating.
• Nausea or vomiting.
• Shortness of breath.
• Known ischaemic heart disease.
• Diabetes, hypertension, hyperlipidaemia or smoking history.
• Family history of premature coronary artery disease.

Aortic dissection screen

• Sudden severe tearing chest pain.
• Pain radiating to the back.
• Syncope.
• Neurological symptoms.
• Unequal arm blood pressures.
• Known hypertension.
• Known aortic aneurysm.
• Connective tissue disease such as Marfan syndrome.
• Recent cocaine or stimulant use.

Musculoskeletal and trauma screen

• Recent fall or injury.
• Heavy lifting or strenuous exercise.
• Pain reproducible with movement.
• Pain reproducible with palpation.
• Localized rib tenderness.
• Recent coughing fit.
• Known osteoporosis.
• Steroid use.

Malignancy and TB screen

• Persistent cough.
• Haemoptysis.
• Weight loss.
• Loss of appetite.
• Night sweats.
• Fever.
• Smoking history.
• Asbestos exposure.
• Previous cancer.
• TB contact.
• Travel or residence in a high TB prevalence area.
• Immunosuppression or HIV risk.

Past medical history

• Asthma.
• COPD.
• Bronchiectasis.
• Previous pneumonia.
• Previous pneumothorax.
• Previous DVT or PE.
• Ischaemic heart disease.
• Heart failure.
• Pericarditis.
• Aortic disease.
• Cancer.
• Tuberculosis.
• Autoimmune disease.
• Recent surgery or hospital admission.

Drug history and allergies

• Current regular medications.
• Anticoagulants.
• Antiplatelets.
• Oestrogen therapy or combined oral contraceptive pill.
• Recent antibiotics.
• Steroids.
• Immunosuppressants.
• Analgesia already taken.
• Drug allergies and reaction.

Family history

• Venous thromboembolism.
• Thrombophilia.
• Premature ischaemic heart disease.
• Aortic dissection or aneurysm.
• Connective tissue disease.
• Autoimmune disease.
• Lung cancer.
• Tuberculosis exposure in household.

Social history

• Smoking status and pack-year history.
• Vaping.
• Alcohol intake.
• Recreational drug use, especially cocaine or stimulants.
• Occupation and asbestos or dust exposure.
• Recent travel.
• Recent immobility.
• Baseline exercise tolerance.
• Living situation and support.
• Impact on work and daily activities.

Ideas, concerns and expectations

• Ask what the patient thinks is causing the pain.
• Ask what they are most worried about.
• Ask whether they are concerned about a heart attack, blood clot, lung collapse or infection.
• Ask what they were hoping would happen today.
• Acknowledge that chest pain can be frightening.

Red flags

• Severe breathlessness.
• Low oxygen saturation.
• Haemoptysis.
• Syncope or collapse.
• Hypotension.
• Central crushing chest pain.
• Tearing pain radiating to the back.
• Unilateral leg swelling.
• Fever with sepsis features.
• Cyanosis.
• New neurological symptoms.
• Known cancer or recent surgery.

Closing the history

• Summarise the key points back to the patient.
• Ask if they would like to add anything else.
• Thank the patient.
• State that you would check observations, oxygen saturation, perform respiratory and cardiovascular examination, ECG and chest X-ray.

3. Physical Examination

The examination should assess severity, oxygenation, respiratory pathology, cardiovascular causes, DVT signs and chest wall tenderness.

Before starting the examination

• Wash hands or use alcohol gel.
• Introduce yourself with name and role.
• Confirm the patient's identity.
• Explain the examination clearly.
• Gain consent.
• Ask whether the patient is comfortable to proceed.
• Position the patient sitting upright or at 45 degrees.
• Expose the chest appropriately while maintaining dignity.
• Ask for a chaperone if appropriate.

Initial assessment

• Look from the end of the bed.
• Assess whether the patient is breathless, cyanosed, pale, sweaty or distressed.
• Assess whether the patient can speak in full sentences.
• Look for shallow breathing due to pain.
• Look for oxygen therapy, monitoring, chest drain or nebuliser.
• Look for scars, trauma or asymmetrical chest movement.
• If acutely unwell, perform ABCDE assessment and call for senior help.

Vital signs

• Respiratory rate.
• Oxygen saturation.
• Heart rate.
• Blood pressure.
• Temperature.
• Level of consciousness.
• Pain score.
• Consider checking blood pressure in both arms if aortic dissection is suspected.

Hands

• Look for peripheral cyanosis.
• Check capillary refill time.
• Look for finger clubbing.
• Look for nicotine staining.
• Look for tremor.
• Assess peripheral temperature.
• Look for splinter haemorrhages if endocarditis is considered.

Pulse and blood pressure

• Assess pulse rate.
• Assess pulse rhythm.
• Tachycardia may suggest pain, PE, infection, hypoxia or shock.
• Irregularly irregular pulse suggests atrial fibrillation.
• Measure blood pressure.
• Hypotension is concerning for shock, massive PE, tension pneumothorax, sepsis or aortic pathology.

Face, mouth and neck

• Look for central cyanosis.
• Look for conjunctival pallor.
• Look for cachexia or weight loss.
• Assess cervical and supraclavicular lymph nodes.
• Check tracheal position.
• Assess jugular venous pressure.
• Look for neck vein distension in tension pneumothorax or tamponade.

Chest inspection

• Inspect chest shape.
• Look for respiratory distress.
• Look for asymmetrical chest movement.
• Look for scars.
• Look for bruising or trauma.
• Look for chest wall deformity.
• Observe respiratory pattern.
• Look for a chest drain if pneumothorax has already been treated.

Palpation

• Assess chest expansion.
• Compare expansion bilaterally.
• Palpate for chest wall tenderness.
• Palpate ribs if trauma or fracture is suspected.
• Palpate for subcutaneous emphysema if pneumothorax or trauma is suspected.
• Assess tactile vocal fremitus if consolidation or effusion is suspected.
• Confirm tracheal position.

Percussion

• Percuss symmetrical areas of the chest.
• Hyperresonance may suggest pneumothorax.
• Dullness may suggest pneumonia, collapse or pleural effusion.
• Stony dullness suggests pleural effusion.
• Compare side to side.

Auscultation

• Auscultate symmetrical areas of the chest.
• Assess air entry.
• Listen for crackles.
• Listen for bronchial breathing.
• Listen for wheeze.
• Listen for pleural rub.
• Assess vocal resonance if consolidation or effusion is suspected.
• Reduced breath sounds on one side may suggest pneumothorax or effusion.

Cardiovascular examination

• Assess JVP.
• Palpate apex beat.
• Auscultate heart sounds.
• Listen for murmurs.
• Listen for pericardial rub if pericarditis is suspected.
• Check for signs of heart failure.
• Assess peripheral oedema.

DVT and peripheral examination

• Inspect legs for asymmetry.
• Look for unilateral calf swelling.
• Palpate for calf tenderness if clinically appropriate.
• Check for pitting oedema.
• Look for superficial venous distension.
• Compare calf size if DVT is suspected.

Abdominal and systemic examination

• Check for abdominal tenderness if referred pain is possible.
• Assess for hepatomegaly if right heart failure is suspected.
• Look for rash or joint signs if autoimmune pleuritis is suspected.
• Assess temperature and signs of sepsis.
• Look for signs of malignancy such as cachexia or lymphadenopathy.

Specific findings to mention in OSCE

• Reduced breath sounds with hyperresonance suggests pneumothorax.
• Tracheal deviation away from the affected side suggests tension pneumothorax.
• Focal crackles, bronchial breathing and dullness suggest pneumonia.
• Pleural rub supports pleurisy, PE or pneumonia.
• Unilateral leg swelling with pleuritic pain suggests PE.
• Pericardial rub with positional chest pain suggests pericarditis.
• Reproducible tenderness suggests musculoskeletal pain but does not automatically exclude serious disease.
• Normal examination does not exclude PE or early pneumothorax.

To complete the examination

To complete my examination, I would review observations, check oxygen saturation, perform ECG, request chest X-ray, blood tests including FBC, U&E, CRP and troponin where appropriate, and consider D-dimer, CT pulmonary angiography, blood gas or echocardiography depending on the suspected diagnosis.

4. Differential Diagnosis

Life-threatening causes

• Pulmonary embolism.
• Tension pneumothorax.
• Acute coronary syndrome.
• Aortic dissection.
• Severe pneumonia with sepsis.
• Cardiac tamponade.

Respiratory causes

• Pneumonia.
• Viral pleurisy.
• Pneumothorax.
• Pulmonary embolism.
• Pleural effusion.
• Lung cancer.
• Tuberculosis.
• Bronchiectasis exacerbation.
• Pulmonary infarction.

Cardiac causes

• Pericarditis.
• Myocarditis.
• Acute coronary syndrome.
• Aortic dissection.
• Pulmonary hypertension with right heart strain.

Chest wall and musculoskeletal causes

• Costochondritis.
• Rib fracture.
• Muscle strain.
• Chest wall trauma.
• Herpes zoster before rash appears.

Systemic and inflammatory causes

• Systemic lupus erythematosus.
• Rheumatoid pleuritis.
• Vasculitis.
• Familial Mediterranean fever in relevant populations.
• Drug-induced pleuritis.

5. Investigations

Bedside tests

• Full observations.
• Oxygen saturation.
• 12-lead ECG.
• Capillary blood glucose if acutely unwell.
• Peak flow if asthma is suspected and safe.
• Urine dip if systemic disease is suspected.
• Pregnancy test in women of reproductive age when relevant.

Blood tests

• Full blood count.
• Urea and electrolytes.
• CRP.
• Liver function tests if systemic disease or malignancy is suspected.
• Troponin if ACS, myocarditis or pericarditis is suspected.
• D-dimer only if PE is possible and clinical probability supports testing.
• Coagulation profile if anticoagulation or bleeding risk is relevant.
• Blood cultures if sepsis or severe pneumonia is suspected.
• Arterial or venous blood gas if hypoxic, severely breathless or unstable.
• Autoimmune tests if inflammatory pleuritis is suspected.

Imaging

• Chest X-ray for pneumothorax, pneumonia, pleural effusion, rib fracture or malignancy.
• CT pulmonary angiography if PE is suspected and imaging is indicated.
• CT chest if malignancy, complex pleural disease or unclear diagnosis is suspected.
• Ultrasound chest if pleural effusion is suspected.
• Echocardiography if pericardial effusion, tamponade, right heart strain or heart failure is suspected.
• CT aorta if aortic dissection is suspected.

Microbiology

• Sputum culture if productive cough or pneumonia is suspected.
• Blood cultures if severe infection or sepsis is suspected.
• Viral swabs depending on local epidemiology and policy.
• Sputum acid-fast bacilli testing if TB is suspected.
• Pleural fluid analysis if pleural effusion is aspirated.

PE-specific investigation pathway

• Assess clinical probability using local PE pathway.
• Use D-dimer only when appropriate for low or intermediate probability.
• Use CT pulmonary angiography when imaging is indicated.
• Consider ventilation-perfusion scanning in selected patients when CTPA is unsuitable.
• Assess for DVT with leg ultrasound if symptoms or pathway indicate.
• Check renal function before contrast imaging when possible.

Important investigation points

• ECG is required because cardiac causes can mimic pleuritic pain.
• Chest X-ray can identify pneumothorax, pneumonia and effusion.
• A normal chest X-ray does not exclude PE.
• D-dimer should not be used indiscriminately.
• Troponin may be relevant in ACS, myocarditis, pericarditis or significant PE.
• Unstable patients need urgent treatment and senior review before prolonged investigations.

6. Management

Management depends on severity and cause. In OSCEs, begin with safety: assess for hypoxia, shock, PE, pneumothorax, ACS, sepsis and aortic dissection before treating as simple pleurisy or musculoskeletal pain.

Immediate approach if acutely unwell

1. Assess using ABCDE.
2. Call for senior help if severe breathlessness, hypoxia, hypotension, syncope, sepsis features or suspected tension pneumothorax is present.
3. Sit the patient upright if breathless.
4. Give oxygen if hypoxaemic according to local oxygen target protocol.
5. Attach monitoring if unstable.
6. Obtain IV access if clinically indicated.
7. Perform ECG and chest X-ray urgently unless immediate emergency treatment is required.
8. Send blood tests and blood gas if indicated.
9. Treat the suspected life-threatening cause according to local protocol.

Analgesia and supportive care

• Provide adequate analgesia.
• Treat pain to allow effective breathing and coughing.
• Avoid excessive sedation in breathless or unstable patients.
• Encourage hydration if appropriate.
• Consider anti-inflammatory medication if pleurisy or pericarditis is diagnosed and there are no contraindications.
• Give clear safety-net advice if managed as outpatient.

If pulmonary embolism is suspected

• Assess haemodynamic stability.
• Give oxygen if hypoxaemic.
• Use local PE probability pathway.
• Arrange D-dimer or CTPA according to clinical probability.
• Consider anticoagulation according to local protocol if PE is likely or imaging is delayed.
• Escalate urgently if hypotension, syncope, severe hypoxia or shock is present.
• Assess bleeding risk before anticoagulation.

If pneumothorax is suspected

• Assess respiratory distress and oxygen saturation.
• Give oxygen if hypoxaemic.
• Request urgent chest X-ray if stable.
• If tension pneumothorax is suspected, call for emergency help and decompress immediately according to local protocol.
• Definitive treatment may involve observation, aspiration or chest drain depending on size, symptoms and guideline.
• Advise smoking cessation and recurrence precautions after stabilisation.

If pneumonia is suspected

• Assess severity and sepsis features.
• Check oxygen saturation and give oxygen if hypoxaemic.
• Arrange chest X-ray and blood tests if indicated.
• Start antibiotics according to local antimicrobial guideline.
• Send sputum and blood cultures if severe or septic.
• Consider admission if hypoxic, confused, hypotensive, frail or high risk.

If pericarditis is suspected

• Perform ECG.
• Check troponin and inflammatory markers.
• Consider echocardiography if effusion or tamponade is suspected.
• Treat with anti-inflammatory therapy according to local guidance if uncomplicated.
• Admit or seek specialist advice if high-risk features are present, such as fever, large effusion, tamponade, immunosuppression, trauma or raised troponin.

If ACS or aortic dissection is suspected

• Treat as a medical emergency.
• Perform immediate ECG and cardiac monitoring.
• Check troponin for suspected ACS.
• Give ACS treatment according to local protocol if indicated.
• Avoid anticoagulation until aortic dissection has been considered when features suggest dissection.
• Arrange urgent CT aorta if dissection is suspected and the patient is stable enough for imaging.
• Escalate early to senior, cardiology or vascular/cardiothoracic teams.

If musculoskeletal pain is likely

• Confirm absence of red flags.
• Check observations and consider ECG or chest X-ray if diagnosis is uncertain.
• Give analgesia.
• Advise gentle activity as tolerated.
• Advise return if symptoms worsen or new breathlessness, fever, haemoptysis or collapse occurs.
• Avoid dismissing chest pain as musculoskeletal without appropriate assessment.

Safety-net advice

• Seek urgent help for worsening chest pain.
• Seek urgent help for shortness of breath.
• Seek urgent help for coughing blood.
• Seek urgent help for collapse, fainting or dizziness.
• Seek urgent help for blue lips or confusion.
• Seek review for persistent fever or worsening cough.
• Seek review if pain does not improve or keeps recurring.

7. Examiner Questions

1. What is pleuritic chest pain?
2. What are the life-threatening causes of pleuritic chest pain?
3. What features suggest pulmonary embolism?
4. What features suggest pneumothorax?
5. What features suggest pneumonia?
6. How does pericarditis classically present?
7. What features suggest aortic dissection?
8. What red flags would you ask about?
9. What observations are important?
10. What initial investigations would you request?
11. When would you request D-dimer?
12. When would you request CTPA?
13. How would you manage suspected tension pneumothorax?
14. How would you manage suspected PE?
15. Why is ECG important in pleuritic chest pain?

Suggested short answers

8. OSCE Pearls

• Pleuritic does not mean harmless.
• Always ask about breathlessness, haemoptysis, syncope and leg swelling.
• Sudden pleuritic pain with breathlessness is PE or pneumothorax until proven otherwise.
• Normal chest examination does not exclude PE.
• Chest X-ray helps find pneumothorax, pneumonia and effusion, but may be normal in PE.
• ECG is essential because cardiac disease can mimic pleuritic pain.
• Fever and focal crackles suggest pneumonia.
• Reduced breath sounds and hyperresonance suggest pneumothorax.
• Pain improved by leaning forward suggests pericarditis.
• Tearing pain radiating to the back suggests aortic dissection.
• Reproducible tenderness supports musculoskeletal pain but does not exclude serious pathology.
• Use PE probability pathways rather than ordering D-dimer for everyone.
• Escalate immediately if hypoxic, hypotensive, cyanosed or collapsed.
• Give adequate analgesia so the patient can breathe and cough effectively.

9. Example Presentation to Examiner

10. References

• AAFP: Pleuritic Chest Pain - Sorting Through the Differential Diagnosis.
• NICE Clinical Knowledge Summary: Pulmonary embolism.
• NICE NG250: Pneumonia diagnosis and management.
• British Thoracic Society pulmonary embolism resources.
• Local emergency medicine, chest pain, PE, pneumothorax, pneumonia and oxygen therapy protocols.