Differential Diagnosis for Patient with Cough and Chest Pain

The patient presents with a cough productive of yellowish phlegm, mid-sternal chest pain worsened by coughing, and a history of recent outdoor work in Alaska. The symptoms and potential exposures guide the differential diagnosis into the following categories:

• Single Most Likely Diagnosis

  • Acute Bronchitis: This is the most likely diagnosis given the patient's symptoms of a productive cough with yellowish phlegm, chest pain that worsens with coughing, and recent exposure to potential allergens or irritants during outdoor work in Alaska. The improvement with an albuterol inhaler and an OTC expectorant/cough suppressant also supports this diagnosis, as these treatments can help alleviate symptoms of bronchitis.

• Other Likely Diagnoses

  • Asthma: The patient's improvement with her daughter's albuterol inhaler suggests possible asthma, especially if the cough and chest pain are related to bronchospasm. The fact that her daughter had similar symptoms could imply a familial component, which is common in asthma.
  • Influenza or Other Viral Respiratory Infections: Although the patient denies fevers, influenza and other viral infections can sometimes present without fever, especially in adults. The productive cough and chest pain could be consistent with a viral respiratory infection, particularly given the recent onset and the fact that her daughter had similar symptoms.
  • Allergic Rhinitis or Sinusitis: Given the patient's exposure to potential allergens during outdoor work and the presence of a productive cough, allergic rhinitis or sinusitis could be contributing to her symptoms, especially if the yellowish phlegm is postnasal drip.

• Do Not Miss Diagnoses

  • Pneumonia: Although the patient denies fevers and shortness of breath, pneumonia must be considered, especially if the cough and chest pain are severe or worsening. Pneumonia can present atypically, and missing this diagnosis could have serious consequences.
  • Pulmonary Embolism (PE): While the patient denies exertional chest pain, dizziness, and shortness of breath, PE is a diagnosis that must be considered due to its potential lethality. The mid-sternal chest pain worsened by coughing could be a presentation of PE, especially if there are underlying risk factors not mentioned.
  • Cardiac Causes (e.g., Myocarditis, Pericarditis): Cardiac causes of chest pain, such as myocarditis or pericarditis, can present with symptoms similar to those described by the patient. These conditions are less likely given the lack of exertional component but should not be entirely ruled out without further evaluation.

• Rare Diagnoses

  • Hypersensitivity Pneumonitis: Given the patient's exposure to potential allergens during outdoor work in Alaska, hypersensitivity pneumonitis is a rare but possible diagnosis. This condition results from an immune system reaction to an inhaled substance, leading to inflammation in the lungs.
  • Occupational Lung Diseases (e.g., Silicosis, Coal Worker’s Pneumoconiosis): Depending on the specific nature of the patient's outdoor work, exposure to certain dusts could lead to occupational lung diseases. However, these would be less likely given the acute onset and the fact that her daughter had similar symptoms.