Differential Diagnosis for Chest and Head Pressure
The patient's symptoms of chest and head pressure, particularly with the radiating nature to the head, suggest a vascular origin. The initial blood pressure reading of 117/116 is notable for its narrow pulse pressure, which may indicate aortic stenosis or other conditions affecting the aorta. Given these details, the differential diagnosis can be categorized as follows:
Single Most Likely Diagnosis
- Hypertensive Emergency: The patient's high diastolic blood pressure (116 mmHg) is concerning for a hypertensive emergency, which can cause symptoms like chest and head pressure due to the excessive strain on blood vessels. The narrow pulse pressure also supports this diagnosis, as it can be seen in conditions where there's increased resistance to blood flow, such as severe hypertension.
Other Likely Diagnoses
- Aortic Stenosis: This condition, characterized by the narrowing of the aortic valve, can lead to chest pain (angina), shortness of breath, and fainting spells (syncope). The narrow pulse pressure observed in the patient could be indicative of severe aortic stenosis.
- Cardiac Ischemia/Myocardial Infarction: Although the patient's symptoms are atypical for a myocardial infarction (MI), the chest pressure could be angina or an MI, especially if there are underlying coronary artery disease risk factors.
- Cervical or Thoracic Aortic Dissection: While less common, the radiating nature of the pain could suggest an aortic dissection, which is a serious condition requiring immediate attention.
Do Not Miss Diagnoses
- Subarachnoid Hemorrhage: Although the patient's symptoms might not classically present as a "thunderclap headache," any severe headache, especially with associated chest pressure, warrants consideration of a subarachnoid hemorrhage due to its high morbidity and mortality if missed.
- Pulmonary Embolism: While the presentation might not be typical, any chest pressure or discomfort should prompt consideration of a pulmonary embolism, given its potential for severe consequences if not promptly diagnosed and treated.
- Aortic Aneurysm (Thoracic or Abdominal): An expanding or ruptured aneurysm could cause chest or abdominal pain that radiates, and it's crucial to identify and manage promptly to prevent catastrophic outcomes.
Rare Diagnoses
- Temporal Arteritis: This condition, more common in older adults, involves inflammation of the blood vessels in the head and could potentially cause headache and, less commonly, chest discomfort if there's associated large vessel involvement.
- Pheochromocytoma: A rare tumor of the adrenal gland that can cause episodic hypertension, leading to symptoms like headache and chest pressure due to catecholamine surges.
Workup and Plan
The initial workup should include:
- ECG to evaluate for cardiac ischemia or signs of hypertensive heart disease.
- Chest X-ray to assess for signs of cardiomegaly, pulmonary edema, or aortic dilatation.
- Blood tests including complete blood count (CBC), basic metabolic panel (BMP), troponin levels to rule out myocardial infarction, and possibly D-dimer if pulmonary embolism is considered.
- Imaging of the aorta (CT or MRI) if aortic dissection or aneurysm is suspected.
- Head CT if subarachnoid hemorrhage is a concern.
The management plan will depend on the diagnosis but may include:
- Blood pressure management with appropriate antihypertensive medications.
- Pain management as necessary.
- Cardiology or vascular surgery consultation for conditions like aortic dissection, aneurysm, or severe aortic stenosis.
- Neurology consultation if subarachnoid hemorrhage or other neurological conditions are suspected.