What is the appropriate evaluation and management for a 16-year-old patient presenting to the pediatric emergency room with chest pain that worsens with movement and deep breathing?

Evaluation and Management of a 16-Year-Old with Chest Pain in the Pediatric ER

Key Questions for History Taking

For a 16-year-old with chest pain that worsens with movement and deep breathing, focus your evaluation on musculoskeletal and respiratory causes while ruling out serious conditions. The following questions should be asked:

• Pain characteristics:

  • Exact location and radiation of pain 1
  • Onset (sudden vs. gradual) 1
  • Duration (fleeting, intermittent, or constant) 1
  • Quality (sharp, dull, pressure, burning) 1
  • Severity (1-10 scale) 1
  • Aggravating factors (specific movements, positions, breathing) 1, 2
  • Alleviating factors (rest, position changes, medications) 1

• Associated symptoms:

  • Fever or recent illness 2
  • Cough or respiratory symptoms 2
  • Palpitations or dizziness 3
  • Syncope or near-syncope episodes 3
  • Gastrointestinal symptoms (reflux, nausea) 4

• Past medical history:

  • Previous similar episodes 3
  • Known cardiac conditions 1
  • Asthma or respiratory conditions 5
  • Recent trauma 4
  • Recent COVID-19 infection or exposure 5

• Family history:

  • Cardiac disease or sudden death 1
  • Connective tissue disorders 1

• Social history:

  • Recent physical activities or sports 2
  • Substance use (smoking, vaping) 6
  • Stress or anxiety 1

Differential Diagnosis

Based on the presentation of chest pain worsening with movement and deep breathing, consider:

• Musculoskeletal causes (most likely):

  • Costochondritis 2, 4
  • Muscle strain 3
  • Rib injury 4

• Respiratory causes:

  • Pneumonia 1, 4
  • Pleuritis 2
  • Pneumothorax/pneumomediastinum (especially with sudden onset in adolescents) 3
  • Pulmonary embolism (rare but serious) 1

• Cardiac causes (less likely but important to exclude):

  • Pericarditis 1
  • Myocarditis 1
  • Arrhythmias 3

• Gastrointestinal causes:

  • Gastroesophageal reflux 4
  • Esophagitis 1

• Psychogenic causes:

  • Anxiety/panic disorder 1
  • Somatization disorder 1

• Other:

  • Herpes zoster (shingles) 1, 2

Physical Examination

• Vital signs:

  • Temperature, heart rate, respiratory rate, blood pressure, oxygen saturation 2

• General appearance:

  • Signs of respiratory distress 2
  • Anxiety or distress 1

• Chest examination:

  • Inspect for chest wall deformities, bruising 2
  • Palpate for tenderness (particularly at costochondral junctions) 1, 2
  • Reproduce pain with palpation or movement 2
  • Auscultate for abnormal breath sounds, friction rubs, decreased breath sounds 1, 2

• Cardiac examination:

  • Auscultate for murmurs, rubs, abnormal heart sounds 1
  • Assess for irregular rhythm 2
  • Check peripheral pulses 1

• Skin examination:

  • Rash or vesicular lesions (herpes zoster) 1, 2

Diagnostic Studies

Based on history and physical examination findings, consider:

• Initial studies for most patients:

  • Electrocardiogram (ECG) 4, 3
  • Chest radiograph (if respiratory symptoms, abnormal lung exam, or concerning history) 4, 5

• Additional studies based on clinical suspicion:

  • Complete blood count (if fever or suspected infection) 5
  • Basic metabolic panel 5
  • Cardiac enzymes (troponin) if cardiac etiology suspected 5
  • D-dimer (if pulmonary embolism suspected) 5
  • Inflammatory markers (ESR, CRP) if inflammatory condition suspected 5
  • Echocardiogram (if abnormal ECG, cardiac murmur, or family history of cardiac disease) 4, 3
  • Pulse oximetry 2

Management Approach

1. For musculoskeletal pain (most likely given pain with movement and deep breathing):

   • NSAIDs for pain relief 6
   • Rest and activity modification 6
   • Reassurance about benign nature 6

2. For respiratory causes:

   • Appropriate antibiotics if pneumonia is diagnosed 2
   • Observation and supportive care for viral pleuritis 2
   • Emergency intervention for pneumothorax (needle decompression if tension pneumothorax) 3

3. For cardiac causes:

   • Cardiology consultation if ECG abnormalities or concerning history 3
   • Anti-inflammatory medications for pericarditis 1

4. For anxiety-related chest pain:

   • Reassurance 1
   • Breathing exercises 1
   • Consider referral to cognitive-behavioral therapy if recurrent episodes 1

Red Flags Requiring Immediate Attention

• Severe respiratory distress or hypoxia 2
• Abnormal vital signs (tachycardia, hypotension) 1
• Syncope with chest pain 3
• Sudden onset of severe pain described as "ripping" or "tearing" 1
• Family history of sudden cardiac death or cardiomyopathy 1
• Abnormal ECG findings 3
• Fever with chest pain and signs of systemic illness 2

Follow-up Recommendations

• For musculoskeletal or idiopathic chest pain (most common):

  • Follow-up with primary care provider if symptoms persist 6
  • Return precautions for worsening symptoms 6

• For diagnosed conditions:

  • Appropriate follow-up based on specific diagnosis 2
  • Consider cardiology referral if cardiac etiology suspected 3

Remember that while most pediatric chest pain is benign and often idiopathic or musculoskeletal in origin (59-74% of cases) 4, 3, a systematic approach is essential to identify the small percentage of cases with serious underlying pathology.