What is the appropriate workup for a 19-year-old with left-sided central chest pain and a sensation of feeling hot, without other associated symptoms?

Workup for a 19-Year-Old with Left-Sided Central Chest Pain and Feeling Hot

For a 19-year-old with left-sided central chest pain and feeling hot without other associated symptoms, the appropriate initial workup should include an electrocardiogram (ECG), focused history, physical examination, and consideration of chest radiography to rule out serious cardiac and non-cardiac causes. 1

Initial Assessment

• A focused history should characterize the chest pain by its quality, location, radiation, onset, duration, precipitating factors, and relieving factors to help determine if the pain is cardiac, possibly cardiac, or noncardiac in origin 1
• Pain described as sharp, fleeting, related to inspiration (pleuritic), positional, or shifting locations suggests a lower likelihood of ischemia 1
• The sensation of "feeling hot" without other symptoms like diaphoresis, dyspnea, nausea, or syncope makes acute coronary syndrome less likely in this young patient 1
• Physical examination should focus on vital signs, cardiovascular assessment, chest wall tenderness, respiratory examination, and signs of anxiety 1

Diagnostic Testing

• A 12-lead ECG should be performed and interpreted within 10 minutes of arrival to assess for cardiac ischemia or injury 1
• Chest radiography is useful to identify potential pulmonary causes of chest pain and evaluate for pneumothorax, pneumonia, or mediastinal abnormalities 1
• In this age group, consider basic laboratory tests including complete blood count and basic metabolic panel 1

Differential Diagnosis Considerations

Musculoskeletal Causes (Common in this age group)

• Costochondritis and other chest wall pain syndromes should be considered, especially if pain is reproducible by palpation 1, 2
• Assess for point tenderness which would suggest musculoskeletal origin rather than ischemia 1

Pulmonary Causes

• Consider pneumothorax or pneumomediastinum, especially if pain is abrupt, continuous, and of short duration 3
• Evaluate for pleuritic pain which may indicate pulmonary involvement 1

Gastrointestinal Causes

• Gastroesophageal reflux disease can mimic cardiac pain and may present as squeezing or burning sensations 1
• Consider if pain occurs after meals or at night, or improves with antacids 1

Psychiatric Considerations

• Anxiety and panic disorders are common causes of chest pain in young adults 1
• The sensation of "feeling hot" may be associated with anxiety or panic attack 1

Cardiac Causes (Less likely but important to exclude)

• Although uncommon in this age group, cardiac arrhythmias and congenital heart disease should be considered 3
• The absence of exertional symptoms, radiation of pain, and associated symptoms makes acute coronary syndrome less likely 1

Further Workup Based on Initial Findings

• If initial evaluation suggests a cardiac cause, consider cardiac biomarkers (troponin) 1
• For suspected gastrointestinal causes with recurrent symptoms, consider a trial of acid suppression therapy 1
• For recurrent, similar presentations with negative cardiac workup, consider referral to a cognitive-behavioral therapist if anxiety is suspected 1
• If air-leak syndrome is suspected based on clinical presentation, careful examination of chest radiograph is essential 3

Important Considerations

• Although cardiac causes are less common in a 19-year-old, they should not be dismissed without appropriate evaluation 3
• Chest pain should not be described as "atypical" as this can be misinterpreted as benign; instead, characterize it as cardiac, possibly cardiac, or noncardiac 1
• Most chest pain in adolescents is idiopathic or musculoskeletal in origin, but timely diagnosis is important to avoid missing life-threatening conditions 3