Differential Diagnosis for Chest Pain Radiating to the Shoulder with Dyspnea

The patient presents with chest pain radiating to the shoulder, dyspnea, hypotension (BP 80/60), and crackles on auscultation. These symptoms suggest a serious underlying condition that requires immediate attention.

• Single Most Likely Diagnosis

  • Acute Pulmonary Embolism (PE): The combination of chest pain, dyspnea, and hypotension, along with the presence of crackles, makes PE a highly likely diagnosis. The radiating pain to the shoulder can be associated with the referred pain from the lung parenchyma or pleura. Hypotension in the setting of PE suggests a high-risk or massive PE, which is a medical emergency.

• Other Likely Diagnoses

  • Myocardial Infarction (MI): Although the pain radiating to the shoulder can be seen in MI, the presence of crackles and severe hypotension might lean more towards a pulmonary issue. However, MI, especially an inferior wall MI, can cause referred pain to the shoulder and can lead to heart failure, explaining the dyspnea and hypotension.
  • Pneumonia: Severe pneumonia can cause chest pain, dyspnea, and hypotension, especially if there is associated sepsis. The crackles on auscultation support this diagnosis, but the radiating shoulder pain is less typical.
  • Cardiac Tamponade: This condition can cause chest pain, dyspnea, and hypotension due to impaired cardiac filling. However, the presence of crackles and the specific pattern of pain radiating to the shoulder are less characteristic.

• Do Not Miss Diagnoses

  • Aortic Dissection: Although less likely given the specific symptoms, aortic dissection is a critical diagnosis that cannot be missed. It typically presents with severe, tearing chest pain that can radiate to the back or shoulder. The hypotension could be due to involvement of the aortic root or dissection into the pericardial space causing tamponade.
  • Tension Pneumothorax: This is a life-threatening condition that can cause chest pain, dyspnea, and hypotension. The absence of a typical tracheal deviation or decreased breath sounds on the affected side does not rule out this diagnosis, especially if the patient is on a ventilator or has a small pneumothorax.
  • Severe Asthma or COPD Exacerbation: While these conditions typically present with wheezing and less commonly with chest pain radiating to the shoulder, they can cause significant respiratory distress and hypotension in severe cases, especially if there is associated pneumonia or pneumothorax.

• Rare Diagnoses

  • Pulmonary Vasculitis (e.g., Wegener's Granulomatosis): These conditions can cause chest pain, dyspnea, and renal issues but are less common and would typically have other systemic symptoms or findings.
  • Esophageal Rupture: This condition can cause severe chest pain and can lead to mediastinitis, sepsis, and hypotension. However, it typically follows a history of vomiting or procedural complications and might not initially present with dyspnea or crackles.

Management

The immediate management of this patient should focus on stabilizing vital signs, particularly blood pressure, and addressing the most likely cause of the symptoms. This may include:

• Fluid Resuscitation: To improve blood pressure.
• Oxygen Therapy: To address hypoxia.
• Pain Management: To reduce discomfort.
• Anticoagulation: If PE is suspected, anticoagulation should be initiated unless contraindicated.
• Imaging Studies: CT pulmonary angiogram (CTPA) for suspected PE, or echocardiogram if cardiac tamponade or MI is suspected.
• Blood Cultures and Antibiotics: If pneumonia or sepsis is suspected.
• Cardiac Monitoring: For potential arrhythmias or further ischemic events.

Given the severity of the presentation, the patient should be managed in an intensive care setting with close monitoring of vital signs and rapid adjustment of the treatment plan as necessary based on diagnostic findings.