Approach to the Case
The patient presents with chest pain associated with tightness, shortness of breath, lightheadedness, and radiation to the back of the neck. The pain is also described as pleuritic. Given the recent CTCA showing severe LCX stenosis and the planned angio, coronary artery disease is a significant consideration. However, the pleuritic nature of the pain and the recent long-haul travel from Australia to the US also introduce other potential diagnoses.
Differential Diagnosis
- Single Most Likely Diagnosis
- Acute Coronary Syndrome (ACS): Given the patient's symptoms of chest pain with tightness, shortness of breath, and the recent finding of severe LCX stenosis on CTCA, ACS is the most likely diagnosis. The planned angio further supports this, as it is a common next step in managing significant coronary stenosis.
- Other Likely Diagnoses
- Pulmonary Embolism (PE): The patient's recent long-haul flight increases the risk of PE, and symptoms such as chest pain (especially if pleuritic), shortness of breath, and lightheadedness can be present in PE. The lack of ischemic features on the ECG does not rule out PE.
- Aortic Dissection: Although less common, the radiation of pain to the back of the neck could suggest an aortic dissection, especially if the pain is severe and tearing in nature. The absence of ischemic features on the ECG and the specific characteristics of the pain (tightness, pleuritic) make this less likely but still a consideration.
- Do Not Miss Diagnoses
- Pulmonary Embolism (PE): As mentioned, PE is critical not to miss due to its high mortality if untreated. The recent travel history and symptoms align with PE, making it a diagnosis that must be considered and ruled out.
- Aortic Dissection: This is another "do not miss" diagnosis due to its high mortality rate if not promptly treated. Any suggestion of aortic dissection (severe, tearing chest pain radiating to the back) warrants immediate investigation.
- Rare Diagnoses
- Pericarditis: Although the pain is described as pleuritic, which could suggest pericarditis, the overall clinical picture and the recent cardiac findings make this less likely. Pericarditis typically presents with sharp, stabbing chest pain that improves with sitting up and leaning forward.
- Esophageal Rupture or Spasm: These conditions can cause severe chest pain but are less likely given the patient's overall presentation and the absence of specific symptoms like dysphagia or odynophagia.
Justification
The approach to this case involves considering the patient's symptoms, recent diagnostic findings, and risk factors for various conditions. The single most likely diagnosis, ACS, is supported by the severe LCX stenosis and the planned angio. Other likely diagnoses, such as PE and aortic dissection, are considered due to the patient's symptoms and risk factors (recent travel, nature of the pain). Do not miss diagnoses are those that are potentially life-threatening if not promptly diagnosed and treated, such as PE and aortic dissection. Rare diagnoses, like pericarditis and esophageal rupture/spasm, are less likely but should be considered if the clinical picture changes or if initial diagnoses are ruled out.