Differential Diagnosis for Chest Pain and Associated Symptoms

The patient presents with chest pain radiating to the scapula, exacerbated by lying on the left side or back, laughing, or swallowing, along with difficulty swallowing, pain with laughing, anxiety, brain fog, depression, and sleep disturbance. Here is a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Gastroesophageal Reflux Disease (GERD): The symptoms of chest pain that worsens with lying down, laughing, or swallowing, along with difficulty swallowing, strongly suggest GERD. The pain radiating to the scapula and the unbearable nature of the pain are also consistent with severe GERD.

• Other Likely Diagnoses

  • Anxiety Disorder: The patient's history of anxiety, brain fog, and feeling overwhelmed at work, which may contribute to chest pain, suggests an anxiety disorder. The exacerbation of symptoms by stressors like work and the impact on sleep support this diagnosis.
  • Costochondritis: This condition, characterized by inflammation of the cartilage that connects the ribs to the breastbone, could explain the chest pain, especially if it worsens with movement or pressure on the chest wall.
  • Musculoskeletal Pain: Given the patient's history of Pilates and the nature of the pain, musculoskeletal strain or injury could be a contributing factor, especially if certain movements exacerbate the pain.

• Do Not Miss Diagnoses

  • Acute Coronary Syndrome (ACS): Although less likely in a young female without traditional risk factors, ACS (including myocardial infarction) must be considered due to the potential for fatal outcomes if missed. The presence of chest pain, even if atypical, necessitates ruling out cardiac causes.
  • Pulmonary Embolism (PE): This is another potentially life-threatening condition that could present with chest pain, especially if it worsens with deep breathing or certain positions. Although the patient's symptoms do not strongly suggest PE, it cannot be overlooked.
  • Esophageal Spasm or Esophageal Rupture: These conditions can cause severe chest pain and difficulty swallowing. Esophageal rupture is a medical emergency, making it a "do not miss" diagnosis.

• Rare Diagnoses

  • Pericarditis: Inflammation of the pericardium, the sac surrounding the heart, can cause chest pain that may improve with sitting up and leaning forward. It is less common but should be considered, especially if there are systemic symptoms like fever.
  • Pneumothorax: Although the patient does not report shortness of breath or recent trauma, a spontaneous pneumothorax could cause chest pain and is a rare but serious condition.
  • Esophageal Cancer: While extremely rare in a 28-year-old, esophageal cancer could explain difficulty swallowing and chest pain. However, this would be an unusual presentation at such a young age without other risk factors or symptoms.