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The patient is a 20-year-old male presenting with chest pain that began one day ago. The pain is worse with movement, and does not radiate. He reports a mild dry cough but denies shortness of breath, palpitations, diaphoresis, nausea, vomiting, or syncope. He denies recent trauma, fever, or leg pain or swelling. He has no history of cardiac disease and no recent prolonged immobility or travel.

Gen: NAD, AAOx3, well-appearing HEENT: NCAT, PERRL, MMM Neck: Supple, full ROM, trachea midline CV: RRR, pulses 2+ throughout, no lower extremity edema Resp: Normal work of breathing, CTAB Chest Wall: Anterior chest wall tenderness to palpation reproducing pain Abd: Soft, non-tender, non-distended Ext: No deformity, full ROM, no edema, distal pulses 2+ throughout Skin: Warm, dry, intact, no rash Neuro: Grossly intact, non-focal Psych: Alert, cooperative, appropriate mood and affect

This 20-year-old male presented with chest pain. The differential diagnosis included acute coronary syndrome, aortic dissection, pulmonary embolism, pneumothorax, pericarditis, myocarditis, pneumonia, esophageal pathology, and musculoskeletal causes. Although his age and lack of cardiac risk factors made acute coronary syndrome and aortic dissection unlikely, these were considered due to the potential for atypical presentations. Pulmonary embolism was also considered, but there was no history of immobilization, surgery, hypercoagulable state, or associated symptoms such as pleuritic pain, hemoptysis, or unilateral leg swelling. He is PERC negative.

Physical examination revealed reproducible chest wall tenderness, without signs of respiratory distress, abnormal cardiac findings, or focal lung findings. This finding strongly supports a musculoskeletal etiology. ECG and chest X-ray were both normal, without evidence of acute ischemia, arrhythmia, pneumothorax, pneumonia, or gross mediastinal abnormalities. The absence of fever, cough, or infectious symptoms further reduced the likelihood of pneumonia or pericarditis. There is no evidence of drug use or trauma.

Given the reproducible chest wall tenderness, reassuring diagnostic studies, and clinical stability, the most likely diagnosis is musculoskeletal chest pain. I discussed the evaluation, diagnostic findings, and low risk for serious pathology with the patient. He was advised to follow up with his primary care provider and to return to the ED for worsening pain, shortness of breath, syncope, or new symptoms. Medical decision-making was high complexity due to the consideration and exclusion of multiple potentially life-threatening diagnoses, review and interpretation of diagnostic studies, and individualized risk assessment.