Differential Diagnosis for Chest Pain in a 42-year-old White Male

Single Most Likely Diagnosis

• Acute Coronary Syndrome (ACS): Given the patient's age and presentation with chest pain, ACS, which includes conditions such as myocardial infarction (MI), is a leading consideration. Risk factors such as hypertension, hyperlipidemia, smoking, and family history of coronary artery disease would increase the likelihood.

Other Likely Diagnoses

• Gastroesophageal Reflux Disease (GERD): Chest pain can be a symptom of GERD, especially if it is accompanied by regurgitation, dysphagia, or relieved by antacids.
• Musculoskeletal Pain: Costochondritis or musculoskeletal strain can cause chest pain, particularly if it is reproducible with movement or palpation.
• Pulmonary Embolism (PE): While less common, PE should be considered, especially if there are risk factors such as recent travel, immobilization, or family history of clotting disorders.
• Pneumonia or Pleuritis: Infections can cause chest pain, especially if it is pleuritic (sharp pain that worsens with breathing).

Do Not Miss Diagnoses

• Aortic Dissection: A life-threatening condition that requires immediate intervention. Risk factors include hypertension, aortic aneurysm, or connective tissue disorders like Marfan syndrome.
• Pulmonary Embolism (PE): Also listed under other likely diagnoses, but included here because it is critical not to miss due to its high mortality rate if untreated.
• Esophageal Rupture: A rare but deadly condition that can present with severe chest pain, often after vomiting or retching.

Rare Diagnoses

• Pericarditis: Inflammation of the pericardium can cause chest pain that may improve with leaning forward.
• Pneumothorax: Air in the pleural space can cause chest pain and shortness of breath, more common in tall, thin males or those with lung disease.
• Acute Aortic Regurgitation: Can cause chest pain due to a sudden increase in volume load on the left ventricle, often accompanied by dyspnea and hypotension.

Each of these diagnoses should be considered in the context of the patient's full history, physical examination, and diagnostic tests such as ECG, chest X-ray, and biomarkers (e.g., troponin).