What are the differential diagnoses and initial management steps for a 16-year-old female presenting with thoracic pain without trauma?

Differential Diagnoses for Thoracic Pain in a 16-Year-Old Female Without Trauma

In a 16-year-old female presenting with non-traumatic thoracic pain, musculoskeletal causes—particularly costochondritis—are the most common etiology and should be your primary consideration, followed by respiratory, cardiac, and psychogenic causes. 1

Initial Clinical Assessment

Obtain a focused history capturing these specific elements:

• Pain characteristics: Exact location, radiation pattern, quality (sharp, dull, pressure-like), and severity 2, 1
• Temporal features: Onset (sudden vs. gradual), duration, and whether pain builds over minutes 2, 1
• Aggravating factors: Physical exertion, emotional stress, coughing, sneezing, deep breathing, or specific body positions 1, 3
• Relieving factors: Rest, position changes, or medications (though nitroglycerin response is not diagnostic) 2
• Associated symptoms: Fever, recent illness, dyspnea, nausea, lightheadedness, palpitations, or syncope 2, 1
• Past medical history: Known cardiac conditions, previous similar episodes, or chronic illnesses 1
• Family history: Cardiac disease, sudden cardiac death, or inherited cardiac conditions 1

Differential Diagnoses by System

Musculoskeletal (Most Common)

• Costochondritis: Dull, continuous chest wall pain aggravated by coughing/sneezing and relieved by rest, with tenderness over the thoracic spine (typically T4-5) and adjacent ribs 3, 4
• Thoracic disc degeneration: Mid-dorsal pain radiating around the chest, aggravated by spinal movement, with pain at extremes of thoracic spinal motion in one or two directions 3, 4
• Musculoskeletal strain: Localized chest wall pain reproducible with palpation or movement 1

Respiratory

• Pneumonia: Chest pain with fever, cough, and recent illness 1
• Pleuritis: Sharp, pleuritic chest pain worsened by deep breathing 1
• Pneumothorax: Sudden-onset sharp chest pain with dyspnea 2

Cardiac

• Pericarditis: Positional chest pain (worse supine, better leaning forward) with or without fever 1
• Myocarditis: Chest pain following viral illness with dyspnea 1
• Acute coronary syndrome: Retrosternal discomfort building gradually over minutes, though rare in this age group without risk factors 2

Psychogenic

• Anxiety/panic disorder: Chest pain with palpitations, dyspnea, and sense of impending doom 1
• Stress-related pain: Recurrent episodes associated with emotional triggers 1

Other Considerations

• Pulmonary embolism: Though uncommon in adolescents, consider with sudden dyspnea and risk factors 2
• Esophageal disorders: Burning retrosternal pain related to meals 2

Physical Examination Priorities

• Chest wall palpation: Assess for reproducible tenderness over costochondral junctions, ribs, or thoracic spine (T4-5 region) 3
• Thoracic spine range of motion: Evaluate for pain at extremes of movement 3
• Cutaneous examination: Check for radicular hyperesthesia (present in 16.4% of thoracic disc cases) 3
• Cardiovascular examination: Assess for murmurs, rubs, or gallops 1
• Respiratory examination: Auscultate for decreased breath sounds, crackles, or pleural rubs 1

Initial Diagnostic Studies

For suspected musculoskeletal causes with typical presentation: Clinical diagnosis without imaging is appropriate 1, 3

When imaging is indicated:

• Chest radiograph: First-line for suspected respiratory causes (pneumonia, pneumothorax) 1
• Electrocardiogram: Obtain for any concern of cardiac etiology, including pericarditis or myocarditis 1
• Echocardiogram: Use when ECG is abnormal or cardiac pathology is suspected 1
• MRI thoracic spine without contrast: Consider for persistent thoracic pain with radicular features or when thoracic disc disease is suspected, as it detects early disc degeneration with 90% sensitivity 4

Management Approach

For musculoskeletal pain (most common):

• Reassurance and education about the benign nature 1, 3
• NSAIDs for pain control 1
• Physical therapy and manual therapy for thoracic spine dysfunction 3
• Advice on back care and activity modification 3

For anxiety-related chest pain:

• Reassurance and breathing exercises 1
• Consider referral to cognitive-behavioral therapy for recurrent episodes 1

For cardiac causes:

• Anti-inflammatory medications for pericarditis 1
• Cardiology consultation for suspected cardiac etiologies 1

For respiratory causes:

• Appropriate antimicrobial therapy for pneumonia 1
• Tube thoracostomy for significant pneumothorax 5

Common Pitfalls to Avoid

• Over-attributing pain to cardiac causes: Cardiac chest pain is uncommon in adolescents without risk factors; musculoskeletal causes are far more prevalent 1, 3
• Dismissing thoracic spine pathology: Young women commonly present with benign thoracic disc degeneration causing chest pain that mimics cardiac or pulmonary disease 3, 4
• Unnecessary imaging: Most musculoskeletal chest pain can be diagnosed clinically without imaging 1, 3
• Failing to provide adequate reassurance: Many adolescents and families fear cardiac disease; clear communication about the benign nature of musculoskeletal pain is therapeutic 1, 3

Follow-Up Recommendations

• Primary care follow-up: Arrange for musculoskeletal or idiopathic chest pain within 1-2 weeks 1
• Return precautions: Instruct patient to return immediately for worsening symptoms, syncope, severe dyspnea, or fever 1
• Specialist referral: Consider cardiology for suspected cardiac etiology or pain management for chronic thoracic pain unresponsive to conservative treatment 1, 6