“Left side of my chest”

DISCUSSION: The likelihood of chest pain representing underlying angina from underlying coronary artery disease, in a 28 yo, is very low. The pain was at rest, with atypical qualities. Classic angina would be described as left sided heaviness or squeezing quality, occurring with exertion, and associated with sweating, shortness of breath, nausea/ vomiting. The pain is usually moderate to severe and can radiate to the neck, jaw or down the left arm/both arms. In this case, the differential diagnoses include esophageal reflux / spasm, costochondritis, pericarditis, pulmonary embolus/infarct (also very low), pleurisy, spontaneous, spontaneous pneumothorax, vasospastic angina (prinzmetals) or coronary dissection. The systems were described as a drink going down wrong to paraphrase. No other associated symptoms were described, such as dyspnea, diaphoresis, nausea or radiation. There was no correlation with exertion, occurring at rest, and no exacerbating or relieving factors. In 20s age range, the differential can be further narrowed down to esophageal spasm, pericarditis, costochondritis/musculoskeletal, pleurisy and coronary spasm/dissection. Pericarditis would be described as sharp and worse with inspiration. That could be ruled out with an ecg (diffuse, upsloping ST segment elevation and PR interval depression) and labs (increased ESR/CRP). Pleurisy would have similar quality, but no abnormalities in the ECG or labs. Spontaneous pneumothorax presents with sharp chest pain and shortness of breath with splinting/shallow, rapid breathing. A standard CXR reveals enlarged, blackened pleural space and compression of the lung on the offending hemi-thorax. Pulmonary emboli are associated with shortness of breath, tachypnea and tachycardia (rapid respiration and heart rate). This patient had no risk factors for deep venous thrombosis/PE, such as surgery/injury/cancer/ immobilization. Coronary vasospasm presents similar to classic angina, and CAD is ruled out with angiography (clean coronaries with no atherosclerotic plaque). ST changes can be noted on the ECG. Pharmacological agents, such as ergonovine , would illicit the spasm narrowing of the coronary artery. Coronary dissection presents similarly, with elevated troponin levels and possible ST depression noted on ECG. CT angiography is the diagnostic test of choice and would show the dissection flap in the offending artery. Both of these entities are less common in this age group and the symptoms described make this unlikely. Which leaves the two most common causes of chest pain in young healthy adults -costochondritis/musculoskeletal and esophageal reflux/spasm. Chondritis is exacerbated by palpating the chest wall and reflux with supine position after meals, particularly spicy foods. GERD is relieved with proton pump inhibitors and chondritis with steroids or NSAIDs.