Differential Diagnosis for Chest Pressure

The patient presents with constant chest pressure that worsens episodically throughout the day without a specific trigger and is exacerbated when lying down. This symptomatology can be associated with various conditions, ranging from cardiac to gastrointestinal and musculoskeletal issues. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis
  • Gastroesophageal Reflux Disease (GERD): The worsening of symptoms when lying down is highly suggestive of GERD, as gravity can exacerbate the reflux of stomach contents into the esophagus, leading to chest pressure and discomfort.
• Other Likely Diagnoses
  • Anxiety or Panic Disorder: These conditions can cause episodic worsening of chest pressure without a clear trigger, and symptoms can be exacerbated by stress or specific situations, including lying down due to increased awareness of bodily sensations.
  • Musculoskeletal Issues: Conditions like costochondritis or musculoskeletal strain can cause chest pressure that worsens with movement or position changes, including lying down.
  • Hyperventilation Syndrome: Often associated with anxiety, this can lead to chest tightness or pressure, especially if the patient experiences episodes of deep or rapid breathing.
• Do Not Miss Diagnoses
  • Acute Coronary Syndrome (ACS): Although the patient's symptoms have been constant for 3 months, it's crucial not to miss ACS, especially if there are any risk factors for coronary artery disease. Atypical presentations can occur, especially in women.
  • Pulmonary Embolism (PE): While less likely with constant symptoms over months, PE can present with chest pressure and worsening dyspnea, and it's a condition that requires immediate attention due to its high mortality rate if untreated.
  • Aortic Dissection: This is a medical emergency that can present with sudden onset of chest pain but can also have a more gradual onset. The worsening of symptoms when lying down is not typical but should not rule out this diagnosis.
• Rare Diagnoses
  • Pericarditis: Inflammation of the pericardium can cause chest pain that may improve with sitting up and leaning forward, but it can also present with more constant pressure.
  • Esophageal Spasm: This condition can cause chest pressure or pain that can be exacerbated by lying down, though it's less common than GERD.
  • Mitral Valve Prolapse: While often asymptomatic, mitral valve prolapse can cause chest discomfort, but it's less likely to be the primary cause of the patient's symptoms.

Each of these diagnoses should be considered in the context of the patient's full medical history, physical examination, and diagnostic tests as appropriate.