Chest wall tenderness does not exclude pulmonary embolism

Pulmonary embolism (PE) is usually associated with pleuritic chest pain, and the presence of chest pain that is reproducible by palpation may lead a clinician to discard this diagnosis. This study assessed whether palpable chest pain predicted the likely absence of a PE in individuals in whom the diagnosis was suspected (acute shortness of breath or chest pain without another obvious aetiology).

Patients (n = 965) were recruited from the database of another study looking at diagnosis of PE. Predictive variables of a PE (the Geneva score) were recorded and whether the pain was reproducible by palpation. A PE was ruled out if the d-dimer concentration was <500 μg/l or if proximal venous ultrasonography and helical computed tomography were both negative. If clinical probability was high, a negative pulmonary angiogram was also required. The overall prevalence of PE was 23%. This was not significantly lower in patients with pain reproducible by palpation (19.9% v 23.8%, p = 0.25). 17% of patients with a PE had palpable chest pain.

In these patients with a suspected PE, chest pain reproducible by palpation was not associated with a lower prevalence of an embolism. Physicians must be cautious not to discount this diagnosis in patients who present with this atypical feature.