Differential Diagnosis for 80-year-old Woman with Sharp Pain between Scapula

Single Most Likely Diagnosis

• Aortic Dissection: The combination of sharp pain between the scapula, significantly elevated systolic blood pressure, and bradycardia (heart rate in the 30s) strongly suggests aortic dissection. The pain's location and nature, along with the hemodynamic instability (hypertension and bradycardia), are classic presentations for this condition.

Other Likely Diagnoses

• Myocardial Infarction (MI): Although the pain is between the scapula, MI can present with atypical pain, especially in the elderly. The bradycardia and hypertension could be related to an MI, particularly if it involves the inferior wall, which can affect the heart's conduction system.
• Pulmonary Embolism (PE): While the primary symptom of PE is dyspnea, sharp pain between the scapula could be a presenting symptom, especially if the embolism is causing pulmonary infarction. However, the significant hypertension and bradycardia are less typical for PE.
• Esophageal Rupture: This condition can cause severe, sharp chest pain that might radiate to the back. However, it is less likely to cause the significant hemodynamic instability seen in this patient without other symptoms like vomiting or difficulty swallowing.

Do Not Miss Diagnoses

• Cardiac Tamponade: Although less likely given the presentation, cardiac tamponade can cause hypotension and bradycardia. The elevated systolic blood pressure in this case makes tamponade less likely, but it's a condition that could rapidly deteriorate and must be considered.
• Pneumothorax: A spontaneous pneumothorax could cause sharp chest pain and, in a tension pneumothorax, lead to hemodynamic instability. However, the presentation would typically include respiratory distress and decreased breath sounds on the affected side.

Rare Diagnoses

• Pancreatitis: While pancreatitis can cause severe back pain, it is less likely to cause the specific combination of hemodynamic instability and sharp pain between the scapula seen in this patient.
• Spinal Epidural Hematoma: This is a rare condition that could cause severe back pain and, depending on the location, could affect blood pressure and heart rate. However, it would be an unusual cause of the specific combination of symptoms and signs presented.

Given the patient's presentation, Aortic Dissection should be ruled out first due to its high mortality rate if not promptly diagnosed and treated. Immediate imaging, such as a CT angiogram, and consultation with a cardiothoracic surgeon or an interventional radiologist may be necessary.