Differential Diagnosis for a 54-year-old Male with Left-Sided Chest Pain

The patient presents with left-sided chest pain that worsens with exertion, a history of atrial fibrillation, and hypertension, but no current use of anticoagulants. The differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis

  • Acute Coronary Syndrome (ACS): Given the exertional nature of the chest pain and the patient's history of hypertension, ACS (including myocardial infarction) is a leading consideration. The absence of shortness of breath or nausea does not rule out ACS, as presentations can vary.

• Other Likely Diagnoses

  • Musculoskeletal Chest Pain: This is a common cause of chest pain and can be exacerbated by movement or exertion. The fact that the pain is localized to one side could support this diagnosis.
  • Gastroesophageal Reflux Disease (GERD): Although the patient denies nausea, GERD can cause chest pain that worsens with exertion due to increased abdominal pressure.
  • Pericarditis: Given the patient's history of atrial fibrillation, pericarditis is a possibility, especially if there's an association with recent viral illness or other inflammatory conditions.

• Do Not Miss Diagnoses

  • Pulmonary Embolism (PE): Although the patient denies shortness of breath or dizziness, PE can present atypically, especially in patients with underlying conditions like atrial fibrillation. The lack of anticoagulation use increases the risk.
  • Aortic Dissection: This is a life-threatening condition that can present with chest pain, often described as tearing or ripping. The history of hypertension is a risk factor.
  • Esophageal Rupture: While less common, esophageal rupture can cause severe chest pain and is a medical emergency.

• Rare Diagnoses

  • Pneumothorax: Spontaneous pneumothorax can cause sudden onset of chest pain and is more common in tall, thin males, but the patient's presentation doesn't strongly suggest this.
  • Chest Wall Syndrome (Tietze's Syndrome): This condition involves inflammation of the cartilages and surrounding tissues of the chest wall and can cause chest pain.

Workup from the Emergency Department

• Electrocardiogram (ECG): Immediate ECG to evaluate for signs of ischemia or infarction.
• Troponin Levels: Serial troponin measurements to assess for myocardial damage.
• Chest X-Ray: To evaluate for pulmonary causes such as pneumothorax or pulmonary edema.
• D-Dimer: If pulmonary embolism is suspected, especially given the atrial fibrillation and lack of anticoagulation.
• Echocardiogram: To assess cardiac function and rule out pericarditis or other cardiac causes.
• Blood Work: Including complete blood count, electrolytes, and renal function tests to evaluate for other potential causes and to guide management.
• CT Angiography of the Chest: If aortic dissection is suspected based on clinical presentation or if other tests are inconclusive.
• Esophageal Studies: If GERD or esophageal rupture is suspected and not ruled out by other means.

This approach ensures a comprehensive evaluation of the patient's chest pain, considering both common and life-threatening causes.