History of Present Illness (HPI)
The patient is a 17-year-old who presented to the clinic with his mother for a follow-up after multiple ER visits. The patient and his mother report that he has undergone cardiac workups on several occasions, all of which have yielded negative results. The patient complains of occasional epigastric pain. He and his mother also mention that he experienced upper respiratory symptoms, prompting two urgent care visits last week. The most recent ER visit was on Friday, where the patient presented with chest tightness. However, both the patient and his mother deny any changes in symptoms since the last ER visit. The patient was offered an EGD (Esophagogastroduodenoscopy) and a chest X-ray but refused both.
Differential Diagnosis
- Single Most Likely Diagnosis
- Anxiety or Panic Disorder: Given the patient's multiple ER visits with negative cardiac workups, occasional epigastric pain, and upper respiratory symptoms without clear etiology, along with symptoms of chest tightness, anxiety or panic disorder is a plausible explanation. These conditions can manifest with a variety of physical symptoms, including chest pain and gastrointestinal distress, in the absence of other medical explanations.
- Other Likely Diagnoses
- Gastroesophageal Reflux Disease (GERD): The patient's epigastric pain could be related to GERD, especially if the pain is exacerbated by eating or lying down. The symptoms of upper respiratory infections could be related to aspiration of gastric contents.
- Hypochondriasis or Illness Anxiety Disorder: The frequent visits to healthcare facilities and the focus on physical symptoms despite negative findings could suggest a psychological component to the patient's presentation.
- Do Not Miss Diagnoses
- Pulmonary Embolism: Although less likely given the patient's age and lack of specific risk factors, pulmonary embolism can present with sudden onset of chest pain and respiratory symptoms. It is crucial to consider this diagnosis due to its high mortality rate if missed.
- Cardiac Conditions (e.g., Pericarditis, Myocarditis): Despite previous negative cardiac workups, it is essential to remain vigilant for cardiac causes of chest pain, especially in a young patient with recurrent symptoms.
- Rare Diagnoses
- Esophageal Spasm or Achalasia: These conditions can cause chest pain and difficulty swallowing. They are less common but should be considered if other diagnoses are ruled out.
- Mitral Valve Prolapse: This condition can cause chest pain, palpitations, and anxiety symptoms. It is relatively rare but could explain some of the patient's symptoms if cardiac workups were incomplete or if the condition was not previously considered.