Differential Diagnosis for a 16-Year-Old with Chest Pain

Given the scenario of a 16-year-old experiencing intermittent chest pain without other symptoms, stable vitals, and the pain being non-crushing and occurring at night when thinking about it, the differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis
  • Anxiety or Stress-Related Chest Pain: This is the most likely diagnosis given the description of the pain being intermittent, non-crushing, and occurring at night when the patient is thinking about it. The absence of other symptoms such as breathlessness, cough, or fever further supports this diagnosis.
• Other Likely Diagnoses
  • Musculoskeletal Chest Pain: This could be due to strained muscles or costochondritis, which is inflammation of the cartilage that connects the ribs to the breastbone. The pain can be sharp and may worsen with movement or deep breathing.
  • Gastroesophageal Reflux Disease (GERD): Although the patient does not report symptoms like heartburn or regurgitation, GERD can sometimes present with chest pain alone, especially if the reflux is reaching the upper esophagus.
• Do Not Miss Diagnoses
  • Acute Coronary Syndrome (ACS): Although rare in a 16-year-old, it is crucial not to miss ACS, which includes conditions such as myocardial infarction. Risk factors such as familial hypercholesterolemia or drug use (e.g., cocaine) could predispose a young person to ACS.
  • Pulmonary Embolism (PE): This is another critical diagnosis not to miss. While less common in teenagers without significant risk factors (e.g., immobilization, family history of clotting disorders), it can be life-threatening.
  • Pericarditis: Inflammation of the pericardium, the sac surrounding the heart, can cause chest pain that may improve with sitting up and leaning forward. It can be due to viral infections or other causes.
• Rare Diagnoses
  • Pneumothorax: A collapsed lung can cause sudden, sharp chest pain and shortness of breath, though the latter is not reported here. It's more common in tall, thin males or those with lung disease.
  • Hypertrophic Cardiomyopathy: A condition where the heart muscle becomes thickened, which can lead to obstruction of blood flow and increased risk of sudden cardiac death. It often presents with exertional chest pain or syncope.

History to Ask

• Family History: Of cardiac diseases, sudden death, or conditions that could predispose to early cardiovascular disease.
• Personal Medical History: Previous chest pain episodes, known heart conditions, or other chronic illnesses.
• Lifestyle and Habits: Smoking, drug use, physical activity level, and dietary habits.
• Symptom Details: Exact location, duration, and triggers of the pain, as well as any factors that relieve it.

Tests Required

• ECG: Already being done, which is appropriate for initial screening of cardiac causes.
• Chest X-Ray: To evaluate lung fields and cardiac silhouette for conditions like pneumothorax or cardiomegaly.
• Blood Tests: Such as troponin levels to rule out myocardial infarction, and possibly inflammatory markers or D-dimer depending on the clinical suspicion.
• Exercise Stress Test or Echocardiogram: If there's a high suspicion of cardiac causes like hypertrophic cardiomyopathy or coronary artery anomalies.
• Upper GI Series or Endoscopy: If GERD is highly suspected and not responding to initial management.

Given the patient's stable condition and the nature of the pain, a thorough history and physical examination, along with the ECG, are the first steps. Further testing can be guided by the findings from these initial evaluations.