Differential Diagnosis for Chest Pain
The patient's presentation of sudden, substernal chest pain, nausea, vomiting, diaphoresis, and electrocardiogram (ECG) changes, along with elevated serum cardiac troponin, suggests a cardiac origin for her symptoms. Here's a categorized differential diagnosis:
Single Most Likely Diagnosis
- Acute Myocardial Infarction (MI): The patient's symptoms of sudden, substernal chest pain, nausea, vomiting, diaphoresis, mild tachycardia, elevated cardiac troponin, and ST elevation on ECG are highly suggestive of an acute MI. The fact that resting improves the pain but does not alleviate it completely is also consistent with this diagnosis.
Other Likely Diagnoses
- Acute Coronary Syndrome (ACS) without MI: Although the troponin level is slightly elevated, which might suggest an MI, the level is not significantly high. ACS without MI could still be a consideration, especially if the troponin level does not continue to rise.
- Pulmonary Embolism (PE): While less likely given the ECG changes and troponin elevation, PE can cause sudden chest pain, nausea, vomiting, and diaphoresis. The absence of respiratory symptoms and normal respirations makes this less likely but not impossible.
- Pericarditis: This condition can cause chest pain that improves with sitting up and leaning forward, but the ECG changes and troponin elevation are more suggestive of myocardial involvement.
Do Not Miss Diagnoses
- Aortic Dissection: Although the patient's presentation does not classically suggest aortic dissection (e.g., tearing chest pain radiating to the back), this condition is potentially lethal if missed. The absence of a significant difference in blood pressure between arms and no mention of a murmur or widened mediastinum on chest X-ray makes this less likely, but it should always be considered in the differential for sudden chest pain.
- Pneumothorax: Tension pneumothorax can cause sudden chest pain and cardiovascular collapse. However, the patient's normal respirations and lack of respiratory distress make this less likely.
Rare Diagnoses
- Myopericarditis: An inflammation of both the myocardium and pericardium, which could explain some of the patient's symptoms and ECG findings, but is less common.
- Spontaneous Coronary Artery Dissection (SCAD): A rare cause of acute coronary syndrome, more common in younger women without traditional cardiovascular risk factors, but should be considered in the differential for any woman presenting with ACS symptoms.