Case Study: A 22-Year-Old Female with Recurrent Chest Pain, Epigastric Pain, and Leg Pain

Introduction:

In clinical practice, patients often present with a complex array of symptoms that span multiple organ systems, posing diagnostic and therapeutic challenges for healthcare providers. This case study explores the presentation, evaluation, and management of a 22-year-old female who presented with recurrent chest pain, epigastric pain, leg pain, shortness of breath, and other systemic symptoms. Her history included long-standing symptoms such as chest pain since childhood, as well as more recent developments following a long flight. The case underscores the importance of a meticulous history, thorough physical examination, and judicious use of diagnostic tools to differentiate between organic and functional causes. Furthermore, it highlights the need for a holistic approach to patient care, addressing both physical and psychological factors contributing to her condition.

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 tummy pain.

History of Present Illness:

A 22-year-old female presents to the clinic with a complex constellation of symptoms that have been ongoing for several months. She reports that her symptoms began approximately 8 months ago after a long flight, during which she experienced pain in her legs. Since then, the leg pain has become recurrent, though it seems to improve with Vitamin B complex and pregabalin (Lyrica).

She also describes experiencing central chest pain since childhood, but recently the pain has assumed a new character—higher up in the chest and more localized to the left side. The chest pain is non-radiating and does not seem to be associated with exertion. Over the past few weeks, she has noticed shortness of breath at night when studying, as well as occasional palpitations. She denies any history of syncope, dizziness, or significant weight loss.

Her abdominal pain is primarily epigastric in nature, often accompanied by nausea. She also mentions painful menstrual periods, for which she takes ibuprofen regularly. There is no history of fever, vomiting, diarrhea, or hematochezia. She denies smoking, alcohol consumption, or illicit drug use. Her only known allergy is to "Doretta."

Physical Examination:

• General Appearance: Alert, oriented, and in no acute distress.
• Vitals: BP: 104/66 mmHg, Pulse: 67 bpm, Temp: 36.9°C, Respiratory Rate: 16/min, BMI: 26.95.
• Head, Eyes, Ears, Nose, Throat (HEENT): Normocephalic, atraumatic; extraocular movements intact bilaterally; sclera anicteric, mucous membranes slightly pale; nasal turbinates normal, right slightly edematous; no post-nasal drip; pharynx, tonsils, teeth, tongue, uvula all normal; pupils equal, round, and reactive to light.
• Neck: Supple, no lymphadenopathy, thyroid normal.
• Cardiovascular: Regular rate and rhythm, no murmurs, rubs, or gallops.
• Respiratory: Clear to auscultation bilaterally, no wheezes or crackles.
• Abdomen: Soft, non-distended, with mild tenderness in the epigastric region. No guarding or rebound tenderness. Bowel sounds present.
• Musculoskeletal: Sternum tender to palpation. No swelling or deformity in the extremities. Decreased bone mineralization noted on imaging.
• Neurological: Intact cranial nerves, normal strength, tone, and reflexes.
• Skin: No rashes, petechiae, or discoloration.

Investigations:

Laboratory Tests:

• Complete blood count (CBC): Mild anemia (Hb: 11.5 g/dL).
• Cardiac enzymes (troponin): Normal.
• D-dimer: Negative.
• Liver function tests (LFTs): Normal.
• Amylase/lipase: Normal.
• Thyroid function tests: Normal.
• Iron studies: Low ferritin, consistent with iron deficiency anemia.
• Vitamin B12 and folate levels: Normal.

Imaging:

• Chest X-ray: Normal.
• ECG: Normal sinus rhythm, no ischemic changes.
• Echocardiogram: Normal.
• CT Pulmonary Angiogram: No evidence of pulmonary embolism.
• Abdominal ultrasound: Normal liver, gallbladder, kidneys, spleen, bladder, and uterus. Gastric lining thickened.
• Doppler ultrasound of lower extremities: No deep vein thrombosis (DVT).
• Spine scan: Decreased bone mineral density (osteopenia).

Differential Diagnosis:

1. Chronic Gastritis/Peptic Ulcer Disease (thickened gastric lining, epigastric pain, nausea, history of NSAID use).
2. Costochondritis (tender sternum, recurrent chest pain since childhood).
3. Mild Anemia (pale mucous membranes, fatigue, shortness of breath).
4. Neuropathic Leg Pain (improvement with Lyrica, history of long flight).
5. Anxiety/Panic Disorder (shortness of breath at night, palpitations, chest pain).
6. Osteopenia/Osteoporosis (decreased bone mineral density, musculoskeletal pain).

Management Plan:

• Gastrointestinal: Start omeprazole 20 mg daily for suspected gastritis/peptic ulcer disease. Avoid NSAIDs for dysmenorrhea; consider alternative treatments like hormonal contraceptives or acetaminophen.
• Musculoskeletal: For costochondritis, recommend rest, avoidance of heavy lifting, and use of topical analgesics or acetaminophen. Prescribe calcium (1000 mg/day) and vitamin D (800 IU/day) supplementation for osteopenia.
• Hematological: Start oral iron supplementation (ferrous sulfate 325 mg twice daily) for iron deficiency anemia. Advise dietary modifications to include iron-rich foods (e.g., spinach, red meat, lentils).
• Neurological: Continue pregabalin (Lyrica) for neuropathic leg pain if effective.
• Psychological: Address anxiety-related symptoms with counseling or relaxation techniques (e.g., mindfulness, breathing exercises). If anxiety persists, consider referral to a psychologist or psychiatrist.
• Follow-Up: Repeat endoscopy or gastric pH monitoring if symptoms persist despite treatment. Monitor bone density with periodic Dual-Energy X-ray Absorptiometry (DEXA) scans. Follow-up CBC in 3 months to assess response to iron therapy.

Conclusion:

This case illustrates the complexity of diagnosing and managing a young patient presenting with overlapping symptoms across multiple organ systems. The key strength in this case was the systematic approach to unraveling the underlying causes through a combination of detailed history-taking, targeted physical examination, and strategic use of laboratory and imaging investigations.

The patient’s tender sternum and history of recurrent chest pain since childhood pointed toward costochondritis, while her epigastric pain, nausea, and thickened gastric lining suggested chronic gastritis or peptic ulcer disease, likely exacerbated by chronic NSAID use for dysmenorrhea. Additionally, her slightly pale mucous membranes and mild anemia were consistent with iron deficiency, possibly due to menstrual blood loss. The improvement in her leg pain with pregabalin highlighted a neuropathic component, potentially related to prolonged immobility during a long flight. Finally, her nighttime shortness of breath and palpitations were likely influenced by anxiety or stress, given the absence of significant cardiopulmonary pathology.

The management plan addressed each identified issue comprehensively. Pharmacological interventions such as proton pump inhibitors for gastritis, iron supplementation for anemia, and pregabalin for neuropathic pain were initiated alongside lifestyle modifications, including dietary changes and avoidance of NSAIDs. Psychological support was also incorporated to manage stress-related symptoms. Follow-up plans were established to monitor her response to treatment and address long-term concerns, such as osteopenia.

Ultimately, this case serves as a reminder that medicine is both an art and a science. While advanced diagnostic tools are invaluable, the cornerstone of effective patient care remains a strong clinician-patient relationship built on trust, empathy, and clear communication. By addressing not only the physical manifestations of disease but also the emotional and psychosocial aspects of health, healthcare providers can deliver comprehensive and compassionate care that truly makes a difference in patients’ lives.