Differential Diagnosis for Sudden Onset of Intense Chest Pain

The symptoms described, including sudden onset of intense, squeezing substernal chest pain radiating to the left arm and jaw, accompanied by sweating, cold, nausea, and shortness of breath (sob), suggest a cardiac origin but also necessitate consideration of other potential causes. The differential diagnosis can be categorized as follows:

• Single Most Likely Diagnosis

  • Acute Myocardial Infarction (MI): The classic presentation of MI includes sudden onset of intense, squeezing substernal chest pain radiating to the left arm, jaw, or neck, often accompanied by diaphoresis, nausea, and shortness of breath. This condition is a medical emergency requiring immediate intervention.

• Other Likely Diagnoses

  • Acute Coronary Syndrome (ACS): This encompasses a range of conditions associated with sudden loss of blood flow to the heart, including unstable angina and non-ST elevation MI. Symptoms are similar to those of MI but may vary in severity and duration.
  • Pulmonary Embolism (PE): While the primary symptom of PE is dyspnea, it can also present with chest pain, especially if the embolism is large or if there is associated pulmonary infarction. The pain is typically sharp and stabbing, worse with deep breathing.
  • Pericarditis: Inflammation of the pericardium can cause sharp, stabbing chest pain that may radiate to the trapezius ridge. The pain is often positional, improving with sitting up and leaning forward.

• Do Not Miss Diagnoses

  • Aortic Dissection: A life-threatening condition where there is a tear in the aorta's inner layer. The pain is often described as tearing or ripping and can radiate to the back. It is crucial to consider this diagnosis due to its high mortality rate if untreated.
  • Esophageal Rupture: Although less common, esophageal rupture can present with severe chest pain, often accompanied by difficulty swallowing and severe retching. It is a surgical emergency.
  • Pneumothorax: Spontaneous pneumothorax can cause sudden onset of sharp chest pain and shortness of breath. The pain is typically worse with deep breathing.

• Rare Diagnoses

  • Chest Wall Syndrome (Tietze's Syndrome): Inflammation of the cartilages and surrounding tissues of the ribs can cause chest pain, but it is typically more localized and accompanied by swelling.
  • Gastroesophageal Reflux Disease (GERD): While GERD can cause chest pain, it is usually more of a burning sensation and associated with eating or lying down.
  • Hypertrophic Cardiomyopathy: This condition can cause chest pain, especially with exertion, due to outflow tract obstruction. However, it is less likely to present with the acute onset of symptoms described.

Each of these diagnoses requires careful consideration based on the patient's history, physical examination, and diagnostic tests such as ECG, troponin levels, and imaging studies.