Differential Diagnosis for Chest Pain in a Young Patient with a Normal EKG

When evaluating a young patient with chest pain and a normal EKG, it's crucial to consider a broad range of potential causes, given the nonspecific nature of chest pain and the limitations of a single normal EKG in ruling out all serious conditions. The differential diagnosis can be organized into the following categories:

• Single Most Likely Diagnosis
  • Musculoskeletal chest pain: This is often the most common cause of chest pain in young patients, resulting from strain or inflammation of the muscles and bones in the chest wall. The normal EKG supports this diagnosis by reducing the likelihood of acute cardiac causes.
• Other Likely Diagnoses
  • Gastroesophageal reflux disease (GERD): GERD can cause chest pain that may mimic cardiac pain, especially if the pain is related to eating or lying down. A normal EKG does not rule out GERD.
  • Anxiety or panic disorder: These conditions can cause chest pain or discomfort, often accompanied by other symptoms like palpitations, shortness of breath, or fear of dying. A normal EKG can help shift the focus towards these diagnoses.
  • Pneumonia or pulmonary embolism (less likely in young patients without risk factors but still possible): Although less common in young patients, these conditions can present with chest pain and may not always have specific findings on a single EKG.
• Do Not Miss Diagnoses
  • Acute coronary syndrome (ACS): Although less common in young patients, ACS (including myocardial infarction) can occur, especially in those with risk factors like familial hypercholesterolemia, drug use (e.g., cocaine), or other conditions. A normal EKG does not completely rule out ACS, especially if the pain is acute.
  • Pulmonary embolism: This is a critical diagnosis to consider, as it can be life-threatening. Risk factors, symptoms like sudden onset of shortness of breath, and further diagnostic tests (like D-dimer and CT pulmonary angiogram) are crucial.
  • Aortic dissection: Extremely rare in young patients without predisposing conditions (like Marfan syndrome), but it is a diagnosis that could be catastrophic if missed. Severe, tearing chest pain is a classic symptom.
• Rare Diagnoses
  • Pericarditis: Inflammation of the pericardium can cause chest pain that may be sharp and improve with leaning forward. While an EKG can show specific changes (like widespread ST elevation), these may not always be present.
  • Spontaneous pneumothorax: More common in tall, thin males, this condition can cause sudden onset of chest pain and shortness of breath. A normal EKG would not rule out this diagnosis.
  • Esophageal rupture or esophagitis: These conditions can cause severe chest pain and are medical emergencies. They might not have specific EKG findings.

Each of these diagnoses requires careful consideration of the patient's history, physical examination, and additional diagnostic tests beyond the initial EKG. The key to managing chest pain effectively is maintaining a broad differential diagnosis until more specific information becomes available.