Differential Diagnosis for Central Chest Pain

Single Most Likely Diagnosis

• Musculoskeletal Chest Pain: Given the description of the pain feeling like being punched and radiating to the jaw, arm, and back, along with a normal troponin and negative ECG, musculoskeletal chest pain is a plausible diagnosis. The patient's history of cannabis use could potentially contribute to muscle relaxation or altered perception, but the primary presentation aligns more closely with musculoskeletal issues.

Other Likely Diagnoses

• Anxiety or Panic Attack: The nature of the pain and the absence of clear cardiac indicators (normal troponin and ECG) could suggest an anxiety or panic attack, especially considering the psychological effects of cannabis.
• Gastroesophageal Reflux Disease (GERD): Non-pleuritic chest pain that radiates and is described in a manner not typical for cardiac issues could be related to GERD, especially if the patient has a history of smoking, which can affect the lower esophageal sphincter.
• Costochondritis: Inflammation of the cartilage that connects the ribs to the breastbone could cause sharp pains that feel like being punched, especially if the patient has been using their chest muscles differently or has an inflammatory condition.

Do Not Miss Diagnoses

• Acute Coronary Syndrome (ACS): Despite a normal troponin at 2 hours and a negative ECG, ACS cannot be ruled out entirely, especially in a patient with a significant smoking history. Early presentation of ACS can sometimes have normal initial troponins.
• Pulmonary Embolism (PE): Although the pain is described as non-pleuritic, a PE should always be considered in the differential for chest pain, especially given the patient's history of smoking, which increases the risk of thromboembolic events.
• Aortic Dissection: This is a life-threatening condition that can present with sudden, severe chest pain radiating to the back. The absence of typical risk factors (e.g., hypertension) does not entirely rule out this diagnosis.

Rare Diagnoses

• Pericarditis: Inflammation of the pericardium can cause sharp, stabbing chest pain that may improve with sitting up and leaning forward. It's less likely given the description but should be considered if other diagnoses are ruled out.
• Esophageal Spasm: Spasms of the esophagus can cause chest pain that mimics cardiac pain. This is relatively rare but could be considered, especially if the patient has a history of esophageal issues or if other diagnoses are excluded.