Differential Diagnosis for Severe Chest Pain in an 18-year-old Woman
Single most likely diagnosis
- Aortic dissection: The patient's symptoms of abrupt onset of severe, sharp, and constant chest pain, combined with significantly elevated blood pressure (166/92 mm Hg) and a systolic ejection murmur, are highly suggestive of aortic dissection. The patient's physical characteristics, such as short stature, micrognathia, cubitus valgus deformity, and scoliosis, may indicate a connective tissue disorder like Turner syndrome, which increases the risk of aortic dissection.
Other Likely diagnoses
- Pulmonary embolism: Although less likely given the clear lungs on auscultation and the absence of distended jugular veins, pulmonary embolism could still be a consideration, especially in a patient with potential underlying coagulopathy or other risk factors not immediately apparent.
- Myocardial infarction: While uncommon in young women without traditional risk factors, myocardial infarction should be considered, especially with the patient's hypertension and tachycardia. However, the absence of ST-segment changes on the ECG makes this less likely.
- Pericarditis: The sharp and constant nature of the chest pain could suggest pericarditis, but the lack of a pericardial friction rub and the presence of a systolic ejection murmur point more towards aortic pathology.
Do Not Miss diagnoses
- Pneumothorax: Although the lungs are clear on auscultation, a pneumothorax could present with sudden onset of sharp chest pain and should be considered, especially if there's any possibility of trauma or underlying lung disease.
- Cardiac tamponade: While the jugular veins are not distended, cardiac tamponade is a life-threatening condition that could present with chest pain and should be ruled out, especially if there's any suspicion of trauma or aortic dissection leading to tamponade.
Rare diagnoses
- Marfan syndrome with aortic root dilatation: Although the patient's physical characteristics do not classically align with Marfan syndrome (e.g., tall stature, arachnodactyly), it's a rare condition that could lead to aortic dissection and should be considered in the differential diagnosis of aortic pathology.
- Ehlers-Danlos syndrome: This is another connective tissue disorder that could increase the risk of aortic dissection, although it is less commonly associated with the specific physical findings in this patient.