Differential Diagnosis for Epigastric Pain

The patient presents with epigastric pain not relieved by antacids, which suggests that the cause may not be solely related to gastroesophageal reflux disease (GERD). Considering the patient's complex medical history, including hypertension, prior stroke, acute coronary syndrome (ACS), gout, anxiety, dementia, and the current medication list, the differential diagnosis can be organized into the following categories:

• Single Most Likely Diagnosis
  • Peptic ulcer disease: Given the patient's use of antacids without relief and a history of pantoprazole (a proton pump inhibitor), peptic ulcer disease is a strong consideration. The patient's age and the presence of multiple comorbidities also increase the likelihood.
• Other Likely Diagnoses
  • Gastroesophageal reflux disease (GERD) exacerbation: Despite the patient being on pantoprazole, GERD could still be a contributing factor, especially if the patient has not been adherent to the medication regimen or if the dose needs adjustment.
  • Acute coronary syndrome (ACS): The patient has a history of ACS, and epigastric pain can sometimes be a presenting symptom of cardiac ischemia, especially in elderly patients.
  • Pancreatitis: Given the epigastric location of the pain and the patient's history of gout (which could be related to alcohol use or other factors increasing the risk of pancreatitis), this diagnosis should be considered.
• Do Not Miss Diagnoses
  • Myocardial infarction (MI): Although the patient has a history of ACS, any new onset of chest or epigastric pain in a patient with cardiovascular risk factors must prompt an evaluation for MI.
  • Aortic dissection: This is a life-threatening condition that can present with severe, tearing chest pain but can also have epigastric pain as a component, especially if the dissection involves the descending aorta.
  • Pulmonary embolism (PE): While less common, PE can present with chest pain and should be considered, especially in patients with risk factors such as recent immobilization or history of deep vein thrombosis.
• Rare Diagnoses
  • Gastric cancer: Although less likely, gastric cancer can present with epigastric pain and should be considered, especially in older adults with new-onset symptoms.
  • Mesenteric ischemia: This condition involves insufficient blood flow to the intestines and can present with severe abdominal pain out of proportion to physical examination findings.

Next Best Steps

Given the differential diagnosis, the next best steps would include:

• Immediate assessment for Do Not Miss Diagnoses such as MI, aortic dissection, and PE through electrocardiogram (ECG), troponin levels, D-dimer, and possibly imaging studies like CT angiography.
• Evaluation for Single Most Likely Diagnosis and Other Likely Diagnoses through upper endoscopy for peptic ulcer disease, adjusting GERD management as needed, and considering pancreatic enzymes and imaging for pancreatitis.
• A thorough review of the patient's medication list to assess for any potential interactions or side effects contributing to the epigastric pain.
• Monitoring of the patient's blood pressure and adjustment of antihypertensive medications as necessary to manage the elevated blood pressure reading.