Differential Diagnosis for Chest Pain with Deep Inspiration in a 70-year-old Female

Single Most Likely Diagnosis

• Pulmonary Embolism: Although not the most common cause of chest pain, the specific characteristic of pain worsening with deep inspiration (pleuritic chest pain) is highly suggestive of a pulmonary embolism, especially in an elderly patient who may have risk factors such as immobility, recent surgery, or malignancy.

Other Likely Diagnoses

• Pneumonia: Can cause pleuritic chest pain, especially if the infection involves the pleura. Elderly patients may not always present with typical symptoms of pneumonia, making diagnosis more challenging.
• Pleurisy: Inflammation of the pleura can cause sharp chest pain that worsens with breathing. This can be due to various causes, including viral infections, pulmonary embolism, or autoimmune diseases.
• Costochondritis: Inflammation of the cartilage that connects the ribs to the sternum, which can cause chest pain that may worsen with deep breathing or movement.

Do Not Miss Diagnoses

• Myocardial Infarction: Although the pain description does not classically suggest myocardial infarction (which is typically described as a heavy or squeezing sensation), atypical presentations are more common in elderly females. Missing a myocardial infarction can be fatal.
• Aortic Dissection: A life-threatening condition where there is a tear in the aorta's inner layer. While it typically presents with severe, tearing chest pain, variations in presentation can occur, and it is crucial not to miss this diagnosis.
• Pneumothorax: Air in the pleural space can cause chest pain that worsens with deep inspiration. A tension pneumothorax is a medical emergency.

Rare Diagnoses

• Pulmonary Vasculitis: Conditions like Wegener's granulomatosis can cause chest pain due to inflammation of the blood vessels in the lungs.
• Diaphragmatic Hernia: Although rare, can cause chest pain that worsens with deep inspiration due to herniation of abdominal contents into the thoracic cavity.
• Esophageal Rupture: A rare but serious condition that can cause severe chest pain, potentially worsening with deep inspiration or swallowing.

Each of these diagnoses requires careful consideration of the patient's history, physical examination, and diagnostic tests to determine the underlying cause of the chest pain.