Differential Diagnosis for 48 yo Female with Chest Pain and Uncontrolled T2DM

• Single Most Likely Diagnosis
  • Acute Coronary Syndrome (ACS): The patient's history of uncontrolled type 2 diabetes mellitus (T2DM) increases her risk for cardiovascular disease. The episodes of chest pain, especially when accompanied by shortness of breath (SOB) and radiating to the back, are classic symptoms for ACS. The fact that the pain is severe (8/10) and occurs both with exertion and at rest further supports this diagnosis.
• Other Likely Diagnoses
  • Gastroesophageal Reflux Disease (GERD): Chest pain that improves with Tylenol but lingers could be indicative of GERD, especially if the pain is exacerbated by lying down or certain foods. However, the severity and radiation of pain to the back make this less likely than ACS.
  • Musculoskeletal Chest Pain: Given the patient's age and the fact that the pain improved with Tylenol, musculoskeletal causes such as costochondritis or musculoskeletal strain should be considered, though the pattern of pain and associated SOB makes this less likely.
• Do Not Miss Diagnoses
  • Pulmonary Embolism (PE): Although less common, PE can present with chest pain and SOB. The fact that the patient has uncontrolled T2DM, which can increase the risk of thrombotic events, makes it crucial not to miss this potentially life-threatening condition.
  • Aortic Dissection: This is a medical emergency that can present with severe, tearing chest pain radiating to the back. Although the patient's symptoms have been intermittent, any suspicion of aortic dissection warrants immediate investigation.
  • Myocardial Infarction (MI): Part of the ACS spectrum, MI is a condition where the blood flow to the heart is blocked, causing damage to the heart muscle. It is critical not to miss this diagnosis due to its high morbidity and mortality.
• Rare Diagnoses
  • Pericarditis: Inflammation of the pericardium can cause chest pain that may improve with sitting up and leaning forward. While possible, the patient's presentation and risk factors make this a less likely diagnosis.
  • Esophageal Spasm: This condition can cause severe chest pain but is less likely given the patient's other symptoms and risk factors for cardiovascular disease.