Differential Diagnosis
The patient's presentation of non-specific chest pain, palpitations, and shortness of breath, along with elevated inflammatory markers and a refusal of medication, suggests a complex interplay of potential diagnoses. The following categories outline the differential diagnosis:
- Single Most Likely Diagnosis
- Anxiety disorder: The patient's symptoms of chest tightness, palpitations, and shortness of breath, combined with a reported increase in anxiety, suggest that an anxiety disorder may be the primary cause of his symptoms. The patient's refusal of medication and attribution of anxiety to his physical symptoms further support this diagnosis.
- Other Likely Diagnoses
- Hyperventilation syndrome: The patient's symptoms of chest tightness and shortness of breath could be related to hyperventilation, which is often associated with anxiety.
- Gastroesophageal reflux disease (GERD): The patient's complaint of epigastric pain could be related to GERD, which can cause chest pain and discomfort.
- Sleep apnea: The patient's elevated hemoglobin and hematocrit (H and H) levels may indicate sleep apnea, which can cause palpitations and other cardiovascular symptoms.
- Do Not Miss Diagnoses
- Cardiac arrhythmia: Although the patient has undergone multiple cardiac workups with negative results, it is essential to consider the possibility of a cardiac arrhythmia, such as atrial fibrillation or supraventricular tachycardia, which can cause palpitations and chest discomfort.
- Pulmonary embolism: Although the patient's symptoms are non-specific, it is crucial to consider the possibility of a pulmonary embolism, which can cause chest pain, shortness of breath, and palpitations.
- Autoimmune disorder: The patient's elevated inflammatory markers (e.g., RA factor) and referral to rheumatology suggest the possibility of an autoimmune disorder, such as rheumatoid arthritis or lupus, which can cause a range of symptoms, including chest pain and palpitations.
- Rare Diagnoses
- Mitral valve prolapse: Although the patient's echocardiogram was normal, mitral valve prolapse can cause palpitations, chest discomfort, and shortness of breath.
- Pneumonia or other infectious diseases: The patient's history of upper respiratory symptoms and urgent care visits suggests the possibility of a respiratory infection, which can cause chest pain, shortness of breath, and palpitations.
- Hematologic disorder: The patient's elevated H and H levels and referral to hematology/oncology suggest the possibility of a hematologic disorder, such as polycythemia vera, which can cause a range of symptoms, including palpitations and chest discomfort.