Differential Diagnosis for Acute Onset Abdominal/Substernal Chest Pain
The patient's presentation of acute onset abdominal/substernal chest pain and nausea, particularly after breakfast, suggests several potential diagnoses. The differential diagnosis can be categorized as follows:
Single Most Likely Diagnosis
- Acute Pancreatitis: The sudden onset of sharp pain in the upper abdomen radiating to the back, especially after eating breakfast, is highly suggestive of acute pancreatitis. The condition is often associated with nausea and can cause significant discomfort. The patient's age and history of arthritis (which may involve the use of medications that could potentially cause pancreatitis) also support this diagnosis.
Other Likely Diagnoses
- Gastroesophageal Reflux Disease (GERD) or Esophagitis: The substernal chest pain and nausea could be indicative of GERD or esophagitis, especially if the pain is related to eating.
- Peptic Ulcer Disease: The acute onset of pain after eating could suggest a peptic ulcer, which can cause sharp, burning pain in the upper abdomen.
- Cholecystitis or Biliary Colic: Although less likely given the lack of specific right upper quadrant pain, cholecystitis or biliary colic could present with upper abdominal pain radiating to the back.
Do Not Miss Diagnoses
- Myocardial Infarction (MI): Although the patient has no prior history of cardiac disease, MI can present atypically, especially in elderly females, with symptoms such as epigastric discomfort or nausea rather than the classic chest pain.
- Aortic Dissection: This is a life-threatening condition that can present with sudden, severe chest or back pain. Although less common, it is crucial not to miss this diagnosis due to its high mortality rate.
- Pulmonary Embolism (PE): While the presentation is not typical for PE, it's essential to consider this diagnosis, especially if there are any risk factors for thromboembolism, due to its potential for high morbidity and mortality.
Rare Diagnoses
- Esophageal Rupture or Perforation: This would be an unusual presentation without a clear history of vomiting or severe retching, but it's a diagnosis that could explain severe chest pain and would require urgent intervention.
- Splenic Infarction: Although rare, this could present with acute onset of left upper quadrant abdominal pain and might be considered if there are specific risk factors such as sickle cell disease or thrombocytosis.
Evaluation should include:
- Laboratory tests: Complete blood count (CBC), electrolytes, liver function tests, amylase, and lipase to evaluate for pancreatitis, and troponins to rule out MI.
- Imaging: Chest X-ray, abdominal ultrasound, and potentially a CT scan of the abdomen to evaluate the pancreas, gallbladder, and aorta.
- ECG to assess for cardiac ischemia.
- Consider echocardiography if there's suspicion of cardiac involvement or aortic dissection.
- Pulmonary embolism workup if risk factors are present or if other diagnoses are ruled out.