Differential Diagnosis for SOB and Chest Pain

The patient presents with shortness of breath (SOB) and chest pain that started a few days ago but has worsened, along with specific ECG findings and medication use. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Acute Coronary Syndrome (ACS): The patient's symptoms of chest pain radiating to the back, described as feeling "tight," and the ECG showing sinus bradycardia with incomplete right bundle branch block (RBBB), in the context of being on metoprolol (a beta-blocker), suggest cardiac ischemia. The worsening of symptoms over a few days also points towards an evolving cardiac issue.

• Other Likely Diagnoses

  • Pulmonary Embolism (PE): Although less likely given the description of the chest pain, PE can cause sudden onset of chest pain and SOB. The presence of sinus bradycardia might be seen in PE, especially if it's large and causing significant hemodynamic effects.
  • Pericarditis: The chest pain radiating to the back could be consistent with pericarditis, especially if it improves with leaning forward. However, the ECG findings would more typically show widespread ST elevation in pericarditis.
  • Gastroesophageal Reflux Disease (GERD): GERD can cause chest pain that might be described as tightness, especially after eating or at night. However, the worsening of symptoms and the specific ECG findings make this less likely.

• Do Not Miss Diagnoses

  • Aortic Dissection: This is a medical emergency that can present with sudden, severe chest pain that radiates to the back. Although the ECG does not specifically suggest dissection, any chest pain described as "tearing" or severe, especially in the context of hypertension or aortic disease, warrants immediate consideration of aortic dissection.
  • Pulmonary Hypertension Crisis: While less common, a crisis in pulmonary hypertension could present with worsening SOB and chest pain, and the use of metoprolol might be relevant in managing symptoms but could also potentially worsen pulmonary hypertension if not carefully managed.
  • Cardiac Tamponade: This condition, characterized by fluid accumulation in the pericardial sac leading to impaired cardiac filling, can cause chest pain, SOB, and hypotension. The ECG might show low voltage QRS or electrical alternans in some cases.

• Rare Diagnoses

  • Spontaneous Coronary Artery Dissection (SCAD): A rare cause of ACS, more common in younger women without traditional cardiovascular risk factors. The presentation can be similar to other forms of ACS.
  • Takotsubo Cardiomyopathy: Also known as stress cardiomyopathy, this condition can mimic ACS with chest pain and SOB but is characterized by a distinctive ballooning of the left ventricle on echocardiography, often triggered by intense emotional or physical stress.