Differential Diagnosis for 63 yo Female Patient

The patient's symptoms and laboratory results suggest a range of possible diagnoses. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Acute Coronary Syndrome (ACS) or unstable angina: Given the patient's history of high cholesterol and carotid blockage, even though currently under control, the symptoms of chest pain, back pain, lightheadedness, and nausea, especially occurring at night, could indicate a cardiac issue. The fact that troponin levels are normal and the EKG is normal does not entirely rule out ACS, as these can be normal in early stages or in cases of unstable angina.

• Other Likely Diagnoses

  • Gastroesophageal Reflux Disease (GERD) or esophageal spasm: The chest pain and nausea could be related to GERD, especially if the pain is exacerbated by lying down or relieved by antacids.
  • Pulmonary Embolism (PE): Although less likely given the normal X-ray and lack of specific respiratory symptoms, PE can present with chest pain and lightheadedness. The high neutrophil count could indicate a stress response or infection, but it's not specific.
  • Anxiety or Panic Attack: The symptoms of chest pain, lightheadedness, and nausea, especially occurring at night, could also be indicative of an anxiety or panic disorder.

• Do Not Miss Diagnoses

  • Aortic Dissection: This is a life-threatening condition that can present with sudden onset of chest or back pain and is more common in individuals with a history of hypertension or atherosclerosis. The fact that the pain occurred at night and there was some relief does not rule out this diagnosis.
  • Myocardial Infarction (MI) with Normal Troponin: Early in the course of an MI, troponin levels may not be elevated. Continuous monitoring and possibly repeating troponin levels are crucial.
  • Pulmonary Embolism (again, due to its potential lethality and the fact that initial tests can sometimes be normal).

• Rare Diagnoses

  • Pericarditis: Inflammation of the pericardium can cause chest pain that may improve with sitting up and leaning forward. The normal EKG does not rule out pericarditis, as the classic EKG findings may not always be present.
  • Esophageal rupture or perforation: Although rare, this condition can present with severe chest pain and would be a medical emergency. The fact that the patient's symptoms have somewhat resolved makes this less likely but still worth considering if other diagnoses are ruled out and symptoms recur or worsen.