What is the most likely diagnosis and recommended management for isolated right-sided chest pain that is reproduced by light pressure on the chest wall with an otherwise normal physical examination?

Right-Sided Chest Pain Reproducible on Palpation

This is musculoskeletal chest pain, most likely costochondritis, and requires no imaging or cardiac workup when examination is otherwise normal and pain is fully reproduced by palpation. 1, 2

Confirming the Musculoskeletal Diagnosis

The key diagnostic feature is reproduction of the patient's exact pain with palpation of the chest wall, which you have already demonstrated on examination. 3, 4 This single finding has high specificity for musculoskeletal origin and markedly reduces the probability of acute coronary syndrome. 5

Critical Features Supporting Musculoskeletal Etiology:

• Pain reproduced by touch/palpation is the hallmark diagnostic criterion 1, 2, 3
• Normal physical examination otherwise (normal vital signs, cardiac auscultation, breath sounds) 1
• Localized, sharp quality rather than diffuse pressure 2
• Right-sided location makes cardiac ischemia extremely unlikely 2

Excluding Life-Threatening Causes (Already Done)

You have effectively ruled out serious pathology, but confirm these were absent:

• No cardiac red flags: No pressure/squeezing quality, no radiation to arm/jaw/neck, no diaphoresis, no dyspnea, no nausea 2, 5
• No pulmonary red flags: No dyspnea, no unilateral absent breath sounds (pneumothorax), no tachycardia suggesting pulmonary embolism 1, 5
• No pleuritic features: Pain not worsening with deep inspiration 1

When to Obtain ECG Despite Musculoskeletal Findings:

Only if patient is >35 years old with cardiac risk factors (hypertension, diabetes, smoking, family history) 6. Otherwise, ECG is not indicated when pain is fully reproducible on palpation. 1, 2

Most Likely Diagnosis: Costochondritis

Costochondritis accounts for 42% of all non-traumatic musculoskeletal chest wall pain and is the single most common cause in this presentation. 1, 6 It presents as:

• Tenderness over costochondral junctions (where ribs meet cartilage) 3, 7
• Pain with palpation that exactly reproduces the patient's complaint 4, 8
• Normal chest X-ray (imaging not needed for diagnosis) 1, 3

Other Musculoskeletal Possibilities:

• Chest wall muscle strain from overuse or minor trauma 3, 7
• Rib stress fracture (if history of severe coughing or repetitive activity) 1
• Slipping rib syndrome (lower ribs, often with clicking sensation) 7

Management

No Imaging Required:

Most musculoskeletal chest wall pain is diagnosed by physical examination alone without need for diagnostic imaging. 2, 3 Chest X-ray and rib series have low yield when pain is reproducible on palpation and examination is otherwise normal. 1

Treatment Approach:

1. Reassurance that this is not cardiac and is self-limited 3, 8
2. NSAIDs (oral ibuprofen or naproxen) for analgesia and anti-inflammatory effect 3, 7
3. Topical NSAIDs as alternative if oral contraindicated 3
4. Avoid aggravating activities temporarily 7
5. Local anesthetic injection at point of maximal tenderness if severe and refractory (diagnostic and therapeutic) 3, 8

Expected Course:

Symptoms typically resolve within 2-4 weeks with conservative management. 7

Common Pitfall to Avoid

Do NOT dismiss right-sided chest pain as "atypical" and therefore benign without proper examination. 1 While right-sided location makes cardiac ischemia unlikely, the term "atypical" is problematic and should be avoided. 1 Instead, you correctly identified this as "noncardiac" based on reproducibility with palpation. 1

In the Multicenter Chest Pain Study, acute myocardial ischemia was diagnosed in 7% of patients whose chest pain was fully reproduced by palpation—though this was in a mixed population without specification of whether pain was completely reproduced. 1 Your patient's completely normal examination otherwise combined with full reproduction of pain makes this musculoskeletal with high confidence. 2, 3