Differential Diagnosis

The patient's presentation of shoulder complaints with no physical abnormalities, combined with extreme stress and an overwhelmed state due to a failing marriage, suggests a complex interplay of psychological and possibly physical factors. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Somatization Disorder: This condition is characterized by multiple, recurring physical complaints (like shoulder pain) that cannot be explained by a medical condition, often related to psychological distress. The patient's stress and marital issues could be manifesting as physical symptoms.

• Other Likely Diagnoses

  • Anxiety Disorder: The patient's extreme stress and feelings of being overwhelmed could be symptoms of an anxiety disorder, which can also manifest with physical complaints such as shoulder tension or pain.
  • Depression: Similar to anxiety, depression can cause somatic symptoms, including pain, and is often associated with significant life stressors like marital problems.
  • Fibromyalgia: Although the physical exam did not show abnormalities, fibromyalgia is a condition characterized by widespread musculoskeletal pain accompanied by fatigue, sleep, memory, and mood issues. Stress can exacerbate symptoms.

• Do Not Miss Diagnoses

  • Myocardial Infarction (MI): Although less likely given the lack of physical findings, it's crucial not to miss an MI, especially if the shoulder pain could be referred pain from the heart. Stress can be a trigger for cardiac events.
  • Pulmonary Embolism: Similar to MI, while less likely, a pulmonary embolism can present with sudden onset of shoulder or chest pain and must be considered, especially if there are risk factors for thromboembolic events.
  • Pancreatitis or Peptic Ulcer Disease: These conditions can cause referred pain to the shoulder and are associated with stress.

• Rare Diagnoses

  • Complex Regional Pain Syndrome (CRPS): A chronic pain condition that most often affects one limb after an injury or trauma. It's less likely given the lack of a reported injury but could be considered if the pain is localized and severe.
  • Neoplastic Processes: Rarely, unexplained pain can be the first symptom of a neoplastic process. While unlikely, it's essential to keep this in mind, especially if other symptoms develop or if the pain persists without explanation.

Each of these diagnoses requires careful consideration of the patient's history, physical examination, and possibly further diagnostic testing to determine the underlying cause of their complaints.