What is the appropriate evaluation and management for a 14-year-old boy with left chest discomfort and body pain who is vitally stable?

Evaluation and Management of a 14-Year-Old Boy with Left Chest Discomfort and Body Pain

In a vitally stable 14-year-old with chest pain, cardiac causes are rare (1-5% of cases), and the evaluation should focus on efficiently excluding life-threatening conditions through targeted history and physical examination, with an ECG obtained within 10 minutes if any cardiac concern exists, followed by reassurance when benign causes are identified. 1

Initial Assessment Priority

Immediate Actions

• Obtain a 12-lead ECG within 10 minutes of presentation to exclude STEMI, pericarditis (widespread ST-elevation with PR depression), or arrhythmias, even if musculoskeletal pain is suspected 2, 1
• Measure vital signs including temperature, heart rate, respiratory rate, and blood pressure to identify tachycardia, tachypnea, or fever 1
• Perform focused physical examination of respiratory, cardiovascular, and musculoskeletal systems 1

Critical Red Flags Requiring Immediate Evaluation

• Exertional chest pain occurring during physical activity or emotional stress suggests possible cardiac ischemia 1
• Syncope or presyncope accompanying chest pain warrants immediate cardiac workup; one pediatric patient with atrial flutter presented only with syncope and chest pain 1, 3
• Sudden onset "ripping" pain radiating to the back suggests aortic dissection (rare in pediatrics) 1
• Severe respiratory distress or signs of cardiac compromise require immediate attention 1

Targeted History Elements

Pain Characteristics That Guide Diagnosis

• Abrupt, continuous pain lasting 1-2 days in older adolescents is characteristic of air-leak syndrome (pneumothorax/pneumomediastinum), which occurred in 1.2% of pediatric chest pain cases 3
• Sharp, pleuritic pain worsening with breathing suggests respiratory etiology including pneumonia or pneumothorax 1
• Sharp pain improving when sitting forward and worsening when supine indicates pericarditis 2, 4
• Fleeting pain lasting only seconds is unlikely to be cardiac 1
• Sharp, localized pain pointed to with one finger and reproducible with chest wall palpation suggests benign musculoskeletal cause 1

Associated Symptoms to Assess

• Fever suggests infection (pneumonia, myocarditis, pericarditis) 1, 4
• Dyspnea and cough suggest respiratory cause 1
• Palpitations or irregular heartbeat warrant arrhythmia evaluation 1
• Recent influenza infection raises concern for post-viral myocarditis or pericarditis 4

Physical Examination Findings

Respiratory System

• Unilateral absence of breath sounds with hyperresonant percussion indicates pneumothorax 5
• Localized pleuritic pain with regional dullness to percussion and egophony suggests pneumonia 5, 1
• Friction rub indicates pleural inflammation or pericarditis 5

Cardiovascular System

• Assess for murmurs, abnormal heart sounds (S3 gallop in myocarditis), and irregular rhythm 1
• Pericardial friction rub confirms pericarditis 5

Musculoskeletal System

• Tenderness of costochondral joints indicates costochondritis, the most common identifiable cause of pediatric chest pain 1, 6
• However, 7% of patients with reproducible chest wall tenderness may still have acute coronary syndrome, so do not assume this excludes cardiac disease 5, 1

Diagnostic Testing Strategy

When to Order Cardiac Troponin

• Measure cardiac troponin only if acute coronary syndrome is genuinely suspected, which is extremely rare in children 1
• Post-influenza myocarditis can present with troponin elevation mimicking ACS 4

Chest Radiography Indications

• Order if respiratory symptoms (cough, dyspnea, fever) suggest pneumonia or pneumothorax 1
• Pneumomediastinum can be difficult to diagnose radiologically without careful examination 3
• Evaluate for cardiomegaly suggesting pericardial effusion 4

Advanced Testing (Rarely Needed)

• Exercise stress testing can be eliminated in most cases using a standardized approach, as it rarely changes management in pediatric chest pain 1
• Ambulatory ECG monitoring is indicated for palpitations with suspected arrhythmia, but not for isolated chest pain without palpitations 1
• Transthoracic echocardiography if pericarditis or myocarditis suspected to assess for pericardial effusion or wall motion abnormalities 4

Most Likely Diagnoses in This Age Group

Idiopathic (Most Common)

• 73.6% of pediatric chest pain cases are idiopathic, typically chronic with benign course 3, 7

Musculoskeletal (8.8%)

• Costochondritis is the most common identifiable cause 3, 6
• Diagnosed by tenderness on palpation of costochondral joints 1

Respiratory (9.3%)

• Pneumonia, pneumothorax, or pneumomediastinum 3

Cardiac (3.8%)

• In one pediatric series: 65% had arrhythmias, 30% had congenital heart disease, 5% had coronary aneurysms from Kawasaki disease 3

Gastrointestinal (2.9%)

• Consider if recurrent pain without cardiac or pulmonary cause; trial of acid suppression therapy reasonable 2

Psychiatric/Anxiety (1.4%)

• 81% of children with unexplained chest pain meet criteria for anxiety disorders 1

Management Approach

If Cardiac Testing is Negative

• Treat as costochondritis with anti-inflammatory medications if musculoskeletal cause identified 5
• Provide thorough explanation taking symptoms seriously and explain the benign nature when organic cause is excluded 1
• Consider referral to cognitive-behavioral therapy if cardiac workup negative and pain persists, as this is reasonable for recurrent presentations without physiological cause 2, 1

Critical Pitfalls to Avoid

• Do not use nitroglycerin response as a diagnostic criterion, as relief does not confirm or exclude myocardial ischemia 5, 1
• Do not delay transfer for troponin testing in office settings; patients with suspected ACS should be transported urgently to ED by EMS 2, 1
• Do not dismiss psychogenic causes or order extensive cardiac testing without clear indications 1
• Do not neglect combined syncope, as further cardiac workup is essential in such patients 3

Follow-Up

• Children should be followed until symptoms resolve 1
• Consider underlying diagnoses (immunodeficiency, congenital anomalies) in cases of recurrent or persistent symptoms 1
• Establish long-term trusting relationship with patient and family to provide reassurance 7