Denouement Hot Seat #13: Chest Pain, SOB, and Arm Numbness

by Mel Tavarez with Emily Willner on the Hot Seat

This is a case of a 16 yo boy with localized chest pain at rest, now asymptomatic and a history of syncope. He had an normal physical exam. 

Thank you to the Jennifer, Moh, Dave, Jamil, and Paul for their thoughtful comments. Chest pain is a common emergency department presentation so the discussion is useful in combating availability bias and premature closure in diagnosis. Please click here to read through their perspectives. Scroll up to see them all.

Here's how you answered our case questions
1. What is the most important next diagnostic step?

Nobody thought that the most important next diagnostic test included troponins or a D-dimer. At the same time, no one wanted to do nothing either.

2. Assuming your diagnostic steps are interpreted as normal, what is your next step?

No one wanted to proceed directly to inpatient admission. The other person said, "I would discuss with cardiology and PMD to facilitate close follow up or consider Holter given h/o palpitations."

Hot Seat Response
by Emily Willner

This case is interesting in that it takes a problem we see very frequently (the healthy child with chest pain) which is most often benign- and throws a few wrenches in it.

Chest pain is a common complaint in the pediatric emergency department, and in healthy children and teens, is most often benign. Chest wall pain, psychogenic causes, asthma, GI/reflux, and pain with no identifiable cause are the most common diagnoses. The key to evaluating these patients is to identify the small minority with serious pulmonary (pneumonia, pneumothorax, pulmonary embolus) or cardiac (ischemia, arrhythmia, pericarditis/effusion, myocarditis) conditions.

When evaluating the child with chest pain, the history and physical exam are critical in guiding testing and evaluation. This patient’s immediate history sounds highly suspicious for a chest wall source, such as “precordial catch”. His pain is resolved and he has a normal exam and normal vital signs. While he doesn’t have reproducible pain, there is nothing else of concern on his exam.

His past history is where things get more interesting: he has a family history of arrhythmia (it would help to know what kind) AND pericarditis, and a recent cardiac evaluation for syncope/palpitations. He also had a recent hospitalization, which might have caused him some immobilization. This would prompt me to ensure I examine his calves for swelling/tenderness and specifically ask about family history of blood clots, since as a teen boy he has none of the other common risk factors for thromboembolic disease. If there were no family history of clotting and no LE findings, I would not pursue thromboemobolic disease given his normal HR, Pox and RR and resolved pain.

As for his cardiac history, while I find it reassuring that he had a reportedly normal echo elsewhere, there are enough red flags in his history (syncope, recurrent palpitations) and his family history that I would definitely screen him with an EKG (all the while wishing I had his cardiac workup results in front of me!).

The history and vitals do not suggest an ongoing cardiac ischemic process (resolved pain, no tachycardia, normal BP, normal cardiac exam), so I would not pursue that diagnosis specifically. Finally, exam does not suggest asthma, pnemothorax, or pneumonia (no ongoing pain or dyspnea, normal Pox, no fever or history of fever or cough). That said, I’ve seen healthy teens with small spontaneous pnemothorax have VERY normal exams and VS, so while I’m inclined to say I wouldn’t Xray him- I also might if there were anything just a bit off.

If his EKG (and CXR) were normal, I’d send him home with very detailed return precautions, and ask the family to call his cardiologist to let them know of the ED visit. If those tests were normal, I wouldn’t do blood work or consult cardiology. If his pain recurred while in the ED or there were abnormalities on EKG, I would.

My most likely diagnosis if EKG/CXR are normal would be precordial catch- a.k.a. “Texidor’s twinge” for those who like eponyms. It is a sudden sharp pain, most commonly in the left anterior chest, which is increased with breathing or moving. It is very intense, can cause quite a lot of anxiety and distress as it is difficult to take normal/deep breaths, and lasts 30 seconds to several minutes. The cause is unknown, but may be a brief intercostal muscle spasm or come from the parietal pleura. That said, this is the Hot Seat, so we’ll see how the story unfolds…

The Denouement
by Mel Tavarez The patient was evaluated with a D-dimer, CXR and EKG; these were all normal preliminarily and he was discharged home.  He was called back to the ED for a final radiology interpretation of an apical pneumothorax on his CXR. He had remained completely asymptomatic and was discharged home again.

This is not the patient's actual CXR and instead a close approximation.

The Hot Seat is a recurrent online case series aimed at facilitating asynchronous sharing of PEM knowledge and experience. Faculty are placed on The Hot Seat and publish their opinions without knowing the case or its outcomes. Cases are all actual cases and are written by PEM fellows at Children's National in Washington, DC. Emily Willner is the faculty advisor on case presentations. Come back again for the next case in our series and we welcome your commentary.