Differential Diagnosis for Severe Chest Pain

The patient's presentation of severe, unbearable chest pain, accompanied by nausea, vomiting, and slight shortness of breath, necessitates a broad differential diagnosis to ensure that all potential causes are considered. The categorization of these diagnoses is crucial for guiding immediate management and further investigation.

• Single Most Likely Diagnosis

  • Acute Pericarditis: This condition is characterized by inflammation of the pericardium, which can cause severe, sharp chest pain that is often described as unbearable and may be accompanied by nausea and vomiting. The pain is typically central, does not radiate, and can be exacerbated by breathing or movement. The recent history of "food poisoning" could potentially be related to a viral etiology, which is a common cause of pericarditis. The slightly diminished lung sounds centrally and the presence of a low-grade fever also support this diagnosis.

• Other Likely Diagnoses

  • Pulmonary Embolism (PE): Although the patient does not have the classic symptoms of PE, such as significant shortness of breath or hemoptysis, it remains a consideration due to the severity of the chest pain and the presence of tachycardia. The recent episode of "food poisoning" could have led to dehydration, potentially increasing the risk of thrombosis.
  • Gastroesophageal Reflux Disease (GERD) or Esophagitis: The history of nausea and vomiting could be related to GERD or esophagitis, which can cause severe chest pain. However, the pain is usually relieved by antacids or position change, which was not the case here.
  • Pneumonia: The low-grade fever and slightly diminished lung sounds centrally could suggest pneumonia, although the lack of cough, sputum production, or significant shortness of breath makes this less likely.

• Do Not Miss Diagnoses

  • Myocardial Infarction (MI): Despite normal troponin assays, MI must be considered, especially in a patient with severe chest pain. Early MI or microinfarctions might not always present with elevated troponins initially.
  • Aortic Dissection: This is a life-threatening condition that presents with severe, tearing chest pain. Although the pain typically radiates to the back, its severity and the presence of tachycardia warrant consideration.
  • Pneumothorax: The slightly diminished lung sounds centrally could suggest a pneumothorax, especially if the patient had recent vomiting that could lead to increased intra-thoracic pressure.

• Rare Diagnoses

  • Esophageal Rupture: Although rare, this condition can present with severe chest pain after an episode of forceful vomiting, as seen in Boerhaave's syndrome.
  • Spontaneous Coronary Artery Dissection (SCAD): A rare cause of acute coronary syndrome, more common in women but can occur in men, especially with a history of intense vomiting that could lead to increased intra-thoracic pressure.