A 25-year-old male has left-sided chest pain for 2 weeks with a normal EKG, what to do?

Management of Left-Sided Chest Pain in a 25-Year-Old Male with Normal ECG

For a 25-year-old male with left-sided chest pain for 2 weeks and a normal ECG, further evaluation is needed to rule out both cardiac and non-cardiac causes, with musculoskeletal causes being most likely in this age group. 1

Initial Assessment

Key History Elements to Obtain:

• Characteristics of pain:
  • Nature: Is it sharp, dull, pressure-like, or stabbing?
  • Onset and duration: Gradual or sudden onset? Constant or intermittent?
  • Location and radiation: Localized or diffuse? Radiating to arm, jaw, or back?
  • Precipitating factors: Exertion, emotional stress, position changes, breathing?
  • Relieving factors: Rest, position changes, medications?
  • Associated symptoms: Shortness of breath, diaphoresis, palpitations, fever?

Physical Examination Focus:

• Vital signs (particularly for tachycardia, fever, hypertension)
• Cardiovascular exam: Heart sounds, murmurs, friction rubs
• Chest wall: Tenderness to palpation (suggests musculoskeletal origin)
• Respiratory: Breath sounds, percussion, egophony
• Skin: Rashes (consider herpes zoster)

Diagnostic Approach

Initial Testing (Already Completed):

• ECG: Normal (reduces likelihood of acute coronary syndrome)

Additional Testing to Consider:

1. Chest X-ray to evaluate for pneumothorax, pneumonia, or widened mediastinum 1

2. Laboratory tests:

   • Complete blood count (to assess for infection)
   • Basic metabolic panel
   • Cardiac biomarkers (troponin) if any concern for cardiac etiology

3. If cardiac etiology still suspected:

   • Consider stress testing if there are cardiac risk factors or exertional component to pain 2

Likely Diagnoses to Consider

Most Common in This Age Group:

1. Musculoskeletal causes (costochondritis, muscle strain)

   • Check for reproducibility with palpation of chest wall
   • Typically worse with movement or deep breathing

2. Anxiety/panic disorder

   • Screen with brief questionnaire if history suggests
   • Often associated with other anxiety symptoms

3. Gastrointestinal causes (GERD, esophageal spasm)

   • May be associated with meals
   • Often burning in quality

4. Pulmonary causes (pneumonia, pneumothorax)

   • Check for fever, respiratory symptoms
   • Evaluate breath sounds carefully

Management Plan

1. If chest wall tenderness is present and vital signs are normal:

   • Trial of NSAIDs for likely musculoskeletal cause
   • Follow-up in 1-2 weeks or sooner if symptoms worsen

2. If any concerning features (dyspnea, syncope, family history of early cardiac disease):

   • Consider referral to emergency department for more comprehensive evaluation

3. If symptoms persist despite initial management:

   • Consider referral for additional testing (echocardiogram, CT chest)

Important Considerations and Pitfalls

• Age is not protective: While cardiac causes are less common in young adults, they can still occur, especially with risk factors

• Beware of anchoring bias: Don't assume musculoskeletal cause without appropriate evaluation

• Duration matters: Two weeks of symptoms makes acute life-threatening causes less likely but doesn't exclude significant pathology

• Normal ECG doesn't rule out all cardiac causes: Conditions like pericarditis can have normal ECGs between episodes

• Consider psychological factors: Chest pain is common in anxiety disorders but remains a diagnosis of exclusion

Remember that while most chest pain in young adults is benign, careful evaluation is still necessary to avoid missing serious conditions.