Differential Diagnosis for a 77-year-old Female with Chest Pains and Abdominal Pain

The patient's presentation of initial chest pain followed by severe generalized abdominal pain, diaphoresis, and abdominal tenderness warrants a broad differential diagnosis. The following categories outline potential causes:

• Single Most Likely Diagnosis
  • Acute Mesenteric Ischemia: This condition is characterized by sudden onset of abdominal pain, which can be severe and out of proportion to physical examination findings. The initial chest pain could be referred pain or a manifestation of the systemic response to ischemia. The patient's age and sudden onset of symptoms make this a plausible diagnosis.
• Other Likely Diagnoses
  • Acute Coronary Syndrome (ACS): Although the patient reports that the chest pain has resolved, ACS can present with referred abdominal pain, especially in elderly females. The diaphoresis and initial chest pain support this consideration.
  • Gastrointestinal Perforation: Conditions like a perforated ulcer can cause sudden, severe abdominal pain and could potentially cause referred chest pain if the perforation irritates the diaphragm.
  • Pulmonary Embolism (PE): While less common, a large PE could cause chest pain and, if associated with significant hypoxia or systemic response, could lead to abdominal pain and nausea.
• Do Not Miss Diagnoses
  • Aortic Dissection: This is a life-threatening condition that can present with sudden, severe chest or abdominal pain, depending on the location of the dissection. The patient's age and hypertension increase the risk.
  • Ruptured Abdominal Aortic Aneurysm (AAA): Similar to aortic dissection, a ruptured AAA can cause severe abdominal pain and is more common in elderly patients with hypertension.
  • Esophageal Rupture: Although less common, an esophageal rupture can cause severe chest pain that radiates to the abdomen and is associated with a high mortality rate if not promptly diagnosed and treated.
• Rare Diagnoses
  • Pancreatitis: While pancreatitis can cause severe abdominal pain, it typically has a more gradual onset and is associated with specific risk factors like gallstones or alcohol use.
  • Cholecystitis: Inflammation of the gallbladder can cause right upper quadrant pain, but the generalized nature of the patient's pain and the absence of specific risk factors make this less likely.

Workup in the Emergency Department

Given the broad differential diagnosis, the workup should be comprehensive:

• Imaging:
  • Chest X-ray to evaluate for pulmonary causes or signs of aortic dissection.
  • Abdominal X-ray to look for signs of bowel obstruction or free air under the diaphragm indicating perforation.
  • CT angiogram of the chest and abdomen with contrast to evaluate for aortic dissection, pulmonary embolism, and mesenteric ischemia.
• Laboratory Tests:
  • Complete Blood Count (CBC) to look for signs of infection or inflammation.
  • Basic Metabolic Panel (BMP) to assess for electrolyte imbalances.
  • Liver function tests (LFTs) and lipase to evaluate for pancreatitis.
  • Troponin and electrocardiogram (ECG) to assess for acute coronary syndrome.
  • D-dimer, although nonspecific, can be used to help rule out pulmonary embolism in low-risk patients.
• Other:
  • Bedside ultrasound to quickly assess for free intraperitoneal fluid or signs of AAA.
  • Consider consultation with surgery or vascular surgery depending on the suspected diagnosis.

This approach ensures that potentially life-threatening conditions are promptly identified and treated.