Differential Diagnosis for 48-year-old Male with Left Sided Chest Pain
Single most likely diagnosis
- Costochondritis: This condition is characterized by inflammation of the cartilage that connects the ribs to the breastbone, leading to sharp pains in the chest that can be positional and tender to the touch. The chronic nature of the pain (3 months) and its positional characteristic make costochondritis a plausible diagnosis.
Other Likely diagnoses
- Musculoskeletal strain: Given the positional nature of the pain, a musculoskeletal strain or injury, possibly from overuse or poor posture, could be a likely cause. The fact that the pain is localized and tender suggests a musculoskeletal origin.
- Gastroesophageal reflux disease (GERD): Although not directly related to positional pain, GERD can cause chest pain that may be perceived as positional due to changes in posture affecting esophageal reflux. The chronic use of certain medications could potentially contribute to or exacerbate GERD symptoms.
- Anxiety or stress-related chest pain: The patient's history of schizophrenia and treatment with escitalopram suggests that anxiety could be a contributing factor. Anxiety and stress can manifest as chest pain, which might be perceived as positional due to changes in breathing patterns or muscle tension.
Do Not Miss (ddxs that may not be likely, but would be deadly if missed)
- Acute coronary syndrome (ACS): Although less likely in a 48-year-old without a clear history of cardiovascular risk factors, ACS (including myocardial infarction) must be considered due to its high mortality rate if missed. The fact that the pain is described as positional and tender might lower the suspicion, but it's crucial to rule out ACS, especially if there are any changes in the character of the pain or associated symptoms like shortness of breath or diaphoresis.
- Pulmonary embolism (PE): This is another potentially life-threatening condition that could present with chest pain, although typically the pain would be more pleuritic (sharp pain that worsens with deep breathing). However, the possibility of PE, especially if there are risk factors for thromboembolism, necessitates consideration.
- Pneumonia or pleuritis: Infections like pneumonia or inflammation of the pleura (pleuritis) can cause chest pain that might be perceived as positional due to the involvement of the pleural surfaces. These conditions are important to consider, especially if there are systemic symptoms like fever or cough.
Rare diagnoses
- Tietze's syndrome: A rare condition similar to costochondritis but involves the inflammation of the cartilages and surrounding tissues of the upper ribs. It's characterized by swelling and tenderness.
- Sickle cell crisis: If the patient has sickle cell disease, a crisis could potentially cause chest pain due to vaso-occlusive episodes affecting the chest wall or lungs.
- Thoracic outlet syndrome: This involves compression of the nerves and/or blood vessels that pass into the thoracic outlet (the space between your collarbone and first rib), which can cause pain in the chest and shoulder region, among other symptoms.