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Posted March 15, 2025PAIN IN CENTER OF CHEST WHEN PRESSED
Case Study: A 22-Year-Old Female with Recurrent Chest Pain, Epigastric Pain, and Leg Pain
Introduction:
Patients often present with complex, multi-system symptoms, creating diagnostic and therapeutic challenges. This case describes a 22-year-old female with recurrent chest pain, epigastric pain, leg pain, shortness of breath, and other systemic symptoms. Her history included long-standing chest pain since childhood and recent leg pain after a long flight. The case emphasizes the need for careful history-taking, thorough physical examination, appropriate diagnostic investigations, and a holistic approach addressing both physical and psychological factors.
Patient Information:
Age: 22 years
Gender: Female
BMI: 26.95 (overweight)
Chief Complaint: Recurrent chest pain, epigastric pain, leg pain, shortness of breath on exertion, nausea, palpitations, and abdominal discomfort
History of Present Illness:
The patient reports symptoms ongoing for several months, beginning approximately eight months ago after a long flight, when she experienced leg pain. Leg pain recurs but improves with Vitamin B complex and pregabalin (Lyrica).
She has central chest pain since childhood, recently more localized to the left side, non-radiating, and unrelated to exertion. She experiences occasional shortness of breath at night when studying and occasional palpitations. No syncope, dizziness, or significant weight loss is reported.
Epigastric pain is often accompanied by nausea. She also has dysmenorrhea, treated with ibuprofen. No history of fever, vomiting, diarrhea, or hematochezia. Denies smoking, alcohol, or illicit drug use. Known allergy: “Doretta.”
Physical Examination:
General Appearance: Alert, oriented, no acute distress
Vitals: BP 104/66 mmHg, Pulse 67 bpm, Temp 36.9°C, Respiratory Rate 16/min, BMI 26.95
HEENT: Normocephalic, atraumatic; extraocular movements intact; sclera anicteric; mucous membranes slightly pale; nasal turbinates normal, right slightly edematous; pharynx, tonsils, teeth, tongue, uvula normal; pupils equal, round, reactive
Neck: Supple, no lymphadenopathy, thyroid normal
Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops
Respiratory: Clear bilaterally, no wheezes or crackles
Abdomen: Soft, non-distended, mild epigastric tenderness, bowel sounds present, no guarding/rebound
Musculoskeletal: Sternum tender to palpation, no extremity swelling or deformity, decreased bone mineralization on imaging
Neurological: Cranial nerves intact, normal strength, tone, and reflexes
Skin: No rashes, petechiae, or discoloration
Investigations:
Laboratory Tests:
CBC: Mild anemia (Hb 11.5 g/dL)
Cardiac enzymes (troponin): Normal
D-dimer: Negative
LFTs: Normal
Amylase/lipase: Normal
Thyroid function tests: Normal
Iron studies: Low ferritin (iron deficiency anemia)
Vitamin B12 and folate: Normal
Imaging:
Chest X-ray: Normal
ECG: Normal sinus rhythm, no ischemic changes
Echocardiogram: Normal
CT Pulmonary Angiogram: No pulmonary embolism
Abdominal Ultrasound: Normal liver, gallbladder, kidneys, spleen, bladder, uterus; gastric lining thickened
Doppler Ultrasound (lower extremities): No DVT
Spine scan: Decreased bone mineral density (osteopenia)
Differential Diagnosis:
Chronic gastritis/peptic ulcer disease (thickened gastric lining, epigastric pain, nausea, NSAID use)
Costochondritis (tender sternum, recurrent chest pain since childhood)
Mild anemia (pale mucous membranes, fatigue, shortness of breath)
Neuropathic leg pain (improved with Lyrica, history of long flight)
Anxiety/panic disorder (shortness of breath, palpitations, chest pain)
Osteopenia/osteoporosis (decreased bone mineral density, musculoskeletal pain)
Management Plan:
Gastrointestinal: Omeprazole 20 mg daily for suspected gastritis/peptic ulcer disease; avoid NSAIDs; consider hormonal contraceptives or acetaminophen for dysmenorrhea
Musculoskeletal: Rest, avoid heavy lifting, topical analgesics/acetaminophen for costochondritis; calcium (1000 mg/day) and vitamin D (800 IU/day) supplementation for osteopenia
Hematological: Oral iron supplementation (ferrous sulfate 325 mg twice daily); include iron-rich foods in diet
Neurological: Continue pregabalin for neuropathic leg pain if effective
Psychological: Counseling, relaxation techniques (mindfulness, breathing exercises); referral to psychologist/psychiatrist if symptoms persist
Follow-Up: Repeat endoscopy or gastric pH monitoring if symptoms persist; monitor bone density with periodic DEXA scans; repeat CBC in 3 months to assess response to iron therapy
Conclusion:
This case illustrates the complexity of managing a young patient with overlapping multi-system symptoms. Systematic history-taking, focused physical examination, and judicious use of laboratory and imaging investigations were crucial in identifying the underlying causes.
Chest pain and tender sternum indicated costochondritis
Epigastric pain, nausea, and thickened gastric lining suggested chronic gastritis/peptic ulcer disease, likely exacerbated by NSAID use
Mild anemia indicated iron deficiency, likely menstrual blood loss
Neuropathic leg pain improved with pregabalin, suggesting a neuropathic component
Nighttime shortness of breath and palpitations likely influenced by anxiety
Key Learning Points:
Systematic Approach: Structured diagnostic process is essential to identify both obvious and subtle contributors to symptoms
Multidisciplinary Focus: Optimal outcomes often require medical, nutritional, and psychological interventions
Individualized Care: Tailored treatment plans improve adherence and patient satisfaction
Long-Term Monitoring: Osteopenia and iron deficiency anemia require ongoing follow-up to prevent complications
Effective patient care integrates physical, psychological, and social aspects, emphasizing the importance of clinician-patient trust, empathy, and communication.