A 38-year-old woman comes to the office due to chest pain. She describes the pain as sharp, localized to an area just left of the sternum, and nonradiating. The pain is constant but worsens somewhat with inspiration and movement. She first noticed the pain while exercising 3 weeks ago, but has experienced it at rest as well. The patient has no fevers, chills, dyspnea, swelling, or difficulty breathing at night. Her medical history is significant for 2 normal vaginal deliveries. Her father had a myocardial infarction at age 60. She does not use tobacco, alcohol, or illicit drugs. On physical examination, blood pressure is 112/69 mm Hg and pulse is 72/min. BMI is 34 kg/m². There is tenderness to palpation over the sternum. Cardiac auscultation reveals a normal S1 and S2 without extra sounds or murmurs. ECG and chest x-ray are normal. Which of the following is the most appropriate next step in management of this patient?

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This patient most likely has musculoskeletal chest pain; costochondritis is the most common cause and presents with tenderness of >1 anterior chondral joints (costochondral or sternochondral joints). The condition is often caused by joint aggravation during physical activity (eg, exercise, lifting). > anterior chondral joints Patients with costochondritis typically have localized pain of the anterior chest that worsens with movement, deep inspiration, or coughing. Physical examination reveals localized tenderness to palpation on the affected portion of chest wall with no appreciable swelling. The course is typically benign and self-limiting with resolution in a matter of weeks; however, in some cases the discomfort may persist for up to a year. Initial management involves reassurance along with topical or systemic analgesics (eg, acetaminophen, nonsteroidal anti-inflammatory drugs). (Choice A) CT scan of the chest is indicated in patients with suspected pulmonary embolism or aortic dissection. Tachycardia would be expected, and tenderness to palpation over the sternum is not typical. (Choice B) An elevated erythrocyte sedimentation rate is nonspecific; however, it may suggest a rheumatologic etiology of chest pain (eg, pleuritis due to systemic lupus erythematosus). The absence of other evidence of rheumatologic disease (eg, joint pains, rash) makes such a diagnosis unlikely. (Choice C) Esophageal pH testing is occasionally used to confirm gastroesophageal reflux disease in patients with persistent symptoms and normal endoscopic findings. Patients typically have intermittent burning chest pain after meals or at night; worsening of the pain with movement or inspiration is not typical. (Choices D and F) Troponin levels are obtained in patients with suspected acute coronary syndrome (ACS), and treadmill stress test is indicated in patients with symptoms suggestive of stable angina (eg, exertional chest pain relieved with rest). Chest pain that worsens with movement and is reproducible on palpation is not consistent with myocardial ischemia. In addition, significant coronary artery disease would be unusual in this young woman. (Choice E) Transthoracic echocardiogram is used to assess for pericardial effusion in patients with acute pericarditis. Patients typically have chest pain that worsens with movement (eg, lying down, respiration); however, tenderness to palpation on the chest wall is not typical. Educational objective: Costochondritis presents with tenderness of >1 costochondral or sternochondral joints and is the most common cause of musculoskeletal chest pain. Patients typically have sharp, localized chest pain that is reproducible with palpation. Treatment involves reassurance and symptomatic pain management. > References: Evaluation of chest pain in primary care patients. (http://www.ncbi.nlm.nih.gov/pubmed/21391528)

A 38-Year-Old Woman Comes to the Office Due to Chest