Differential Diagnosis for Chest Pain

The patient's complaint of chest pain that worsens with inspiration or lying supine and lessens by leaning forward suggests a condition that affects the chest cavity and is influenced by position and respiratory movements. Here's a differential diagnosis organized into categories:

• Single most likely diagnosis

  • Acute Pericarditis: This condition is characterized by inflammation of the pericardium, the sac surrounding the heart. The pain typically improves when the patient leans forward and worsens when lying down or with deep breathing, matching the patient's symptoms. The mechanism involves the pericardium's irritation, which is exacerbated by movements that increase friction between the pericardial layers.

• Other Likely diagnoses

  • Pulmonary Embolism (PE): While PE typically presents with sudden onset dyspnea, tachypnea, and possibly chest pain that worsens with deep breathing, the positional component of the pain can sometimes mimic pericarditis. However, the pain associated with PE is usually more pleuritic.
  • Pneumonia or Pleurisy: Inflammation of the lung parenchyma or the pleura can cause chest pain that worsens with deep breathing or coughing. The pain can be positional but typically does not improve with leaning forward as characteristically seen in pericarditis.

• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)

  • Myocardial Infarction (MI): Although the classic presentation of MI is chest pain that may radiate to the arm, jaw, or neck and is not typically positional, atypical presentations can occur, especially in women, diabetics, or the elderly. It's crucial to consider MI in the differential diagnosis due to its high morbidity and mortality if missed.
  • Aortic Dissection: This is a life-threatening condition where there is a tear in the aorta's wall, which can cause severe, tearing chest pain that can be affected by position. Although the pain is often described as migrating, any severe chest pain should prompt consideration of aortic dissection.

• Rare diagnoses

  • Pneumomediastinum: Air in the mediastinum can cause chest pain that may be worsened by position and deep breathing. This condition is less common and usually associated with trauma, lung disease, or as a complication of medical procedures.
  • Esophageal Spasm or Rupture: These conditions can cause severe chest pain but are less likely to present with the specific positional characteristics described. However, they should be considered, especially if there are associated symptoms like dysphagia or if the pain is related to eating.