Differential Diagnosis for Chest Pain

The following differential diagnosis is organized into categories to facilitate a thorough assessment and plan.

• Single Most Likely Diagnosis
  • Costochondritis: This is often the most likely diagnosis for patients presenting with chest pain that is sharp, stabbing, and localized to the chest wall, particularly if it is reproducible with palpation or movement. The pain is typically exacerbated by activities that increase the movement of the ribs, such as deep breathing or coughing.
• Other Likely Diagnoses
  • Myocardial Infarction (MI): Although less common than costochondritis in many populations, MI is a critical diagnosis to consider, especially in patients with risk factors such as hypertension, diabetes, high cholesterol, smoking, or a family history of heart disease. The pain associated with MI is often described as a heavy, squeezing, or pressure-like sensation in the chest that may radiate to the arms, back, neck, jaw, or stomach.
  • Pulmonary Embolism (PE): This diagnosis should be considered, especially in patients with risk factors such as recent surgery, immobilization, cancer, or a history of deep vein thrombosis. The pain associated with PE is typically sudden in onset, sharp, and worsens with deep breathing (pleuritic chest pain).
• Do Not Miss Diagnoses
  • Aortic Dissection: Although rare, this condition is life-threatening and requires immediate intervention. Patients typically present with severe, tearing chest pain that radiates to the back.
  • Pneumothorax: This condition can cause sudden, severe chest pain that worsens with breathing and can be life-threatening if not promptly treated.
• Rare Diagnoses
  • Pericarditis: Inflammation of the pericardium, the sac surrounding the heart, can cause chest pain that improves with sitting up and leaning forward. It is less common than the other diagnoses listed but should be considered, especially in patients with recent viral illnesses or autoimmune disorders.
  • Esophageal Rupture or Perforation: This is a rare but serious condition that can cause severe chest pain, often associated with difficulty swallowing, vomiting, or abdominal pain, particularly after forceful vomiting or an endoscopic procedure.

Each of these diagnoses requires a careful and thorough evaluation, including a detailed history, physical examination, and appropriate diagnostic tests such as ECG, troponin levels, D-dimer, chest X-ray, and CT scans, to determine the underlying cause of the chest pain and to guide the management plan.