Differential Diagnosis for Acute Onset Chest Pain

The patient's presentation of acute onset right-sided chest pain that transitions to the center of the chest, with sharp characteristics and high severity, warrants a broad differential diagnosis. The following categories outline potential causes, prioritized by likelihood and urgency.

• Single Most Likely Diagnosis

  • Acute Coronary Syndrome (ACS): Although the patient has no known cardiac history, the acute onset of severe chest pain, especially with a transition from sharp to a more centralized location, raises concern for ACS, including myocardial infarction. The lack of response to nitroglycerin does not rule out this diagnosis.

• Other Likely Diagnoses

  • Pulmonary Embolism (PE): The acute onset of chest pain, particularly if it started while standing and was sharp, could suggest a pulmonary embolism, especially in the absence of other obvious causes.
  • Pneumothorax: Sharp chest pain that is localized and severe could indicate a pneumothorax, which might not have been immediately apparent without imaging.
  • Costochondritis or Musculoskeletal Pain: Given the sharp nature of the pain and its initial localization to one side, musculoskeletal causes such as costochondritis should be considered, although the severity and transition of pain might be less typical.

• Do Not Miss Diagnoses

  • Aortic Dissection: Although less likely given the patient's presentation and lack of known risk factors (e.g., hypertension, Marfan syndrome), aortic dissection is a critical diagnosis to consider due to its high mortality rate if missed. The pain's severity and potential for radiation (though not present in this case) warrant consideration.
  • Esophageal Rupture: This condition is rare but life-threatening. The sharp, severe pain could potentially be esophageal in origin, especially if there was an attempt to eat or drink something that caused a rupture, though the patient denies recent illness or heavy lifting.
  • Pulmonary Hypertension Crisis: Though rare and less directly suggested by the patient's symptoms, any condition leading to severe, unexplained chest pain should prompt consideration of pulmonary hypertension, especially if there are underlying risk factors not mentioned.

• Rare Diagnoses

  • Pericarditis: Inflammation of the pericardium can cause sharp, severe chest pain, often with a positional component. While less likely, it remains a consideration, especially if other diagnoses are ruled out.
  • Spontaneous Coronary Artery Dissection (SCAD): A rare cause of acute coronary syndrome, more common in women without traditional cardiovascular risk factors, presenting with sudden onset chest pain.