Differential Diagnosis

The patient presents with new-onset chest pain, tender costochondral junctions, and a history of CABG x 3, along with recent onset of high blood pressure and intermittent chest pain. The following differential diagnoses are considered:

• Single Most Likely Diagnosis
  • Gastroesophageal Reflux Disease (GERD): The patient's symptoms of significant heartburn and chest pain that radiates to the left arm, without other typical cardiac symptoms like shortness of breath or sweating, suggest GERD as a likely cause. The recent onset of high blood pressure and the timing of the pain (starting with the onset of winter) could be coincidental or related to increased reflux due to colder weather or postural changes.
• Other Likely Diagnoses
  • Costochondritis: Given the tender costochondral junctions, costochondritis is a plausible diagnosis. This condition can cause chest pain and tenderness, especially with palpation, and can be exacerbated by activities or movements that increase stress on the chest wall.
  • Hypertensive Crisis: Although the patient's high blood pressure started being monitored in June, the recent increase in blood pressure could potentially lead to hypertensive crises, which might manifest as intermittent chest pain among other symptoms.
  • Stable Angina: Despite the CABG x 3, the patient could still experience angina, especially if there are areas of the heart not well-perfused by the grafts or if there has been progression of native coronary artery disease.
• Do Not Miss Diagnoses
  • Myocardial Infarction (MI): Although the patient's symptoms do not classically present as an MI (e.g., no radiating pain to the neck, no shortness of breath), any chest pain in a patient with a history of CABG and recent onset of high blood pressure must be considered for MI due to its high mortality if missed.
  • Aortic Dissection: This is a life-threatening condition that can present with sudden onset of chest pain, which might be described as tearing or radiating to the back. Although less likely given the description, it cannot be missed.
  • Pulmonary Embolism (PE): Especially given the recent major surgery, PE is a consideration, though the lack of symptoms like shortness of breath or cough makes it less likely.
• Rare Diagnoses
  • Pericarditis: Inflammation of the pericardium can cause chest pain that improves with sitting up and leaning forward. It's less likely given the description but could be considered if other diagnoses are ruled out.
  • Esophageal Spasm: This condition can cause chest pain that mimics cardiac pain but is usually associated with difficulty swallowing or a sensation of food getting stuck.
  • Tietze's Syndrome: Similar to costochondritis but involves the cartilages of the upper ribs and can cause sharp pains, it's a rare condition but should be considered in the differential for chest wall pain.