History of Present Illness (HPI)
The patient is a 20-year-old male presenting with intermittent left shoulder pain that began approximately 1 year ago. The pain radiates from the abdomen to the left shoulder and is associated with occasional epigastric pain. The symptoms are exacerbated by physical activity, with the current pain severity rated as 1/10. Despite multiple ER visits and negative workups, no definitive diagnosis has been established. The patient has a history of mildly elevated blood pressure but denies diaphoresis, palpitations, or radiation of pain to the neck. He also denies any specific injury to the abdomen or shoulder.
Differential Diagnosis
- Single Most Likely Diagnosis
- Gastroesophageal Reflux Disease (GERD): The patient's symptoms of epigastric pain and radiation to the left shoulder, exacerbated by physical activity, could be indicative of GERD. The negative workups and lack of other symptoms such as diaphoresis or palpitations also point towards a gastrointestinal cause.
- Other Likely Diagnoses
- Peptic Ulcer Disease: The patient's epigastric pain and radiation to the left shoulder could be consistent with peptic ulcer disease, especially given the intermittent nature of the symptoms.
- Functional Dyspepsia: This condition is characterized by recurring epigastric pain or discomfort, which could be exacerbated by physical activity, and may radiate to the shoulder.
- Musculoskeletal Strain: Although the patient denies any specific injury, musculoskeletal strain or overuse could contribute to the shoulder pain, especially if the patient has been engaging in physical activity that exacerbates the symptoms.
- Do Not Miss Diagnoses
- Myocardial Infarction or Cardiac Ischemia: Although the patient denies diaphoresis, palpitations, or radiation of pain to the neck, cardiac causes must be considered, especially given the patient's history of mildly elevated blood pressure.
- Pulmonary Embolism: This is a life-threatening condition that can present with sudden onset of chest pain or shoulder pain, and must be ruled out, especially if the patient has any risk factors.
- Pancreatitis: The patient's epigastric pain and radiation to the left shoulder could be indicative of pancreatitis, which requires prompt medical attention.
- Rare Diagnoses
- Gallbladder Disease: Although less likely, gallbladder disease could cause epigastric pain radiating to the shoulder, especially if the patient has a history of gallstones or other gallbladder pathology.
- Splenetic Infarction: This is a rare condition that could cause left shoulder pain, especially if the patient has a history of sickle cell disease or other conditions that increase the risk of splenic infarction.