Differential Diagnosis for Pleuritic Chest Pain in a 70-year-old Patient
Single Most Likely Diagnosis
- Pulmonary Embolism (PE): Given the patient's history of previous stroke, previous ischemic bowel, and acute limb ischemia, along with the current presentation of pleuritic chest pain and tachycardia (HR 96), PE is a highly plausible diagnosis. The patient is already on apixaban, which might not be sufficient to prevent further thromboembolic events, especially if the dose is not adequate or if there are other underlying factors contributing to hypercoagulability.
Other Likely Diagnoses
- Acute Coronary Syndrome (ACS): Although the patient's saturations and other observations are okay, the presence of pleuritic chest pain and a history of ischemic events (stroke, ischemic bowel, and acute limb ischemia) suggests a possible cardiac origin of the pain, which could be related to ACS.
- Pneumonia or Bronchitis: These conditions can cause pleuritic chest pain, especially in an elderly patient. However, the absence of other respiratory symptoms and the fact that the rest of the observations, including saturations, are okay, makes this less likely but still a consideration.
- Musculoskeletal Chest Pain: This is a common cause of chest pain and can be pleuritic in nature, especially if the pain is related to the chest wall or the muscles involved in breathing.
Do Not Miss Diagnoses
- Aortic Dissection: Although less likely given the lack of other specific symptoms such as tearing chest pain or significant blood pressure differences between limbs, aortic dissection is a diagnosis that cannot be missed due to its high mortality rate. The patient's history of hypertension is not mentioned, but the presence of previous ischemic events could suggest vascular disease.
- Cardiac Tamponade: This condition can present with chest pain and could be a complication of a previous cardiac condition or procedure. It is less likely given the absence of specific signs like hypotension or muffled heart sounds but is crucial not to miss.
- Pneumothorax: Especially in the context of pleuritic chest pain, a pneumothorax could be life-threatening and requires immediate diagnosis and treatment. The fact that the patient's saturations are okay does not rule out a small pneumothorax.
Rare Diagnoses
- Pulmonary Arteritis (e.g., Takayasu Arteritis, Giant Cell Arteritis): These conditions are less common and typically present with additional symptoms such as fever, weight loss, or specific findings on examination. However, they could cause pleuritic chest pain and are important to consider in the differential diagnosis, especially if other causes are ruled out.
- Esophageal Rupture or Perforation: This would typically present with severe, sudden-onset chest pain and possibly other symptoms like difficulty swallowing or vomiting. It is less likely given the description of pleuritic chest pain but is a rare condition that could be considered if other diagnoses are excluded.