What is the next step in managing a 16-year-old boy with chest pain and normal chest X-ray (CXR) and electrocardiogram (ECG)?

Management of Chest Pain in a 16-Year-Old Boy with Normal CXR and ECG

The next step in managing a 16-year-old boy with chest pain and normal chest X-ray and ECG should be a detailed history and focused physical examination to identify non-cardiac causes, followed by referral for appropriate subspecialty evaluation based on suspected etiology. 1

Initial Assessment

When evaluating chest pain in adolescents with normal initial studies, consider:

• Pain characteristics:

  • Exertional vs. non-exertional 2
  • Location, quality, duration, and radiation
  • Precipitating and relieving factors
  • Associated symptoms (dyspnea, diaphoresis, syncope)

• Family history:

  • Sudden cardiac death
  • Aborted sudden death
  • Hyperlipidemia
  • Pulmonary hypertension 2

• Physical examination:

  • Focused cardiac examination
  • Chest wall tenderness
  • Respiratory findings
  • Abdominal examination

Diagnostic Approach

Common Causes in Adolescents

• Musculoskeletal pain (60-65%) - Most common cause in pediatric patients 3, 4
• Pulmonary causes (10-15%) - Including asthma, pneumonia
• Psychological causes (5-10%) - Anxiety, panic disorder
• Gastrointestinal causes (3-5%) - GERD, esophagitis
• Cardiac causes (<1-5%) - Rare but important to exclude 3

Risk Stratification

1. Low risk features:

   • Non-exertional pain
   • Reproducible with palpation
   • Brief duration
   • No concerning family history
   • Normal vital signs
   • Normal ECG and CXR (already confirmed)

2. High risk features (requiring urgent evaluation):

   • Exertional chest pain
   • Syncope with exertion
   • Family history of sudden death
   • Abnormal cardiac examination

Next Steps Based on Suspected Etiology

If Musculoskeletal Pain is Suspected:

• Reassurance and NSAIDs
• Follow-up if symptoms persist

If Respiratory Cause is Suspected:

• Pulmonary function testing
• Referral to pulmonology if indicated 2

If Gastrointestinal Cause is Suspected:

• Trial of antacids/PPIs
• Referral to gastroenterology if indicated 2

If Psychological Cause is Suspected:

• Screening for anxiety/depression
• Referral to mental health services

If Cardiac Concern Persists Despite Normal Initial Tests:

• Exercise stress testing
• Holter/event monitoring
• Echocardiogram 2, 1

Important Considerations

• Cardiac causes of chest pain are rare in adolescents (<1% in most studies) but should not be missed 3
• Non-cardiac chest pain in adolescents has an excellent prognosis
• Reassurance is an important component of management once serious causes are excluded 2
• Appropriate subspecialty referral should be based on suspected etiology rather than routine cardiac referral 3

Common Pitfalls to Avoid

• Over-investigation of benign chest pain
• Failure to recognize exertional symptoms that may indicate cardiac pathology
• Missing non-cardiac but serious causes (e.g., pulmonary embolism, pneumothorax)
• Inadequate reassurance to patient and family about benign nature of most pediatric chest pain 2

Remember that while most chest pain in adolescents is benign, a systematic approach is essential to identify the small percentage of patients with potentially serious conditions requiring specific intervention.