Differential Diagnosis

• Single most likely diagnosis
  • Gastroesophageal reflux disease (GERD) or peptic ulcer disease: The patient was given a "pink lady" (likely a mixture used to help with heartburn or stomach upset) and a prescription for Pantaloc (pantoprazole, a proton pump inhibitor), suggesting an initial suspicion of acid-related disease. The return of pain and emesis (vomiting) after the initial treatment, along with the lack of response to the "pink lady," could indicate worsening or uncontrolled GERD or a peptic ulcer.
• Other Likely diagnoses
  • Gastritis: Inflammation of the stomach lining could cause pain and vomiting, especially if the patient hasn't started the prescribed pantoprazole, which could help reduce stomach acid.
  • Esophagitis: Inflammation of the esophagus, possibly due to acid reflux, could cause chest pain and difficulty swallowing, potentially leading to vomiting.
  • Musculoskeletal pain: The chest pain could be musculoskeletal in origin, especially if the patient has been straining or has poor posture, though the presence of emesis might make this less likely.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.)
  • Acute coronary syndrome (ACS): Although the troponin is 0.00 and the ECG shows a new incomplete right bundle branch block (RBBB) but no other signs of ischemia, ACS must always be considered in patients with chest pain. The new ECG finding could be a red flag, and clinical correlation along with further testing might be necessary.
  • Pulmonary embolism (PE): Sudden onset of chest pain and vomiting could be indicative of a PE, especially if there are risk factors such as recent travel, immobilization, or family history.
  • Aortic dissection: Although less common, aortic dissection is a life-threatening condition that can present with sudden, severe chest pain and might be associated with vomiting. The absence of specific ECG changes or troponin elevation does not rule out this diagnosis.
• Rare diagnoses
  • Esophageal rupture or perforation: A severe condition that could present with chest pain and vomiting, especially if there was forceful vomiting.
  • Pneumonia: Could present with chest pain and vomiting, especially in older adults or those with significant comorbidities.
  • Cardiac tamponade: Although rare, could present with chest pain and potentially vomiting if there is significant impairment of cardiac function.