Differential Diagnosis for 63 yo Female Patient

The patient's symptoms of chest pain, back pain, lightheadedness, and nausea, especially occurring at night and improving after 20 minutes with residual mild chest pain, along with a history of high cholesterol and carotid blockage, suggest a cardiovascular origin. The laboratory findings of a high neutrophil count and low lymphocyte count may indicate an acute inflammatory or infectious process, but in this context, they could also be seen in the setting of acute stress or a cardiovascular event.

• Single Most Likely Diagnosis

  • Acute Coronary Syndrome (ACS): Given the patient's history of high cholesterol and carotid blockage, ACS (including myocardial infarction) is a highly plausible diagnosis. The symptoms of chest pain and back pain, especially occurring at rest, are classic for ACS. The improvement after 20 minutes could be due to spontaneous resolution or partial resolution of the coronary occlusion.

• Other Likely Diagnoses

  • Pulmonary Embolism (PE): Although less likely than ACS given the patient's cardiovascular history, PE could present with sudden onset chest pain, back pain, and lightheadedness. The absence of typical symptoms like dyspnea or cough does not rule out PE.
  • Gastroesophageal Reflux Disease (GERD) or Esophageal Spasm: These conditions can cause chest pain that may be confused with cardiac pain, especially if the pain is burning or related to eating. However, the presence of back pain and lightheadedness makes these diagnoses less likely.
  • Musculoskeletal Pain: Given the nocturnal occurrence, musculoskeletal pain could be considered, but the combination of symptoms and the patient's history makes this less likely.

• Do Not Miss Diagnoses

  • Aortic Dissection: This is a life-threatening condition that can present with sudden, severe chest or back pain and is more likely in patients with a history of hypertension or atherosclerosis. The patient's symptoms of chest and back pain, along with lightheadedness, necessitate consideration of this diagnosis.
  • Cardiac Tamponade: Although less common, cardiac tamponade can present with chest pain, lightheadedness, and nausea, especially if there is a significant pericardial effusion. This diagnosis is critical to consider due to its high mortality if not promptly treated.
  • Pulmonary Hypertension Crisis: Given the patient's history of carotid blockage, if she has underlying pulmonary hypertension, a crisis could present with similar symptoms.

• Rare Diagnoses

  • Spontaneous Coronary Artery Dissection (SCAD): This is a rare cause of ACS, more common in younger women without traditional cardiovascular risk factors, but can occur in any demographic.
  • Pericarditis: Inflammation of the pericardium can cause chest pain that may improve with sitting up and leaning forward. It's less likely given the patient's presentation but should be considered, especially if there's a pericardial friction rub on examination.