Differential Diagnosis for Substernal Chest Pain Radiating to Jaw
Single Most Likely Diagnosis
- Esophageal Spasm or Esophagitis: Given the nature of the pain (substernal chest pain radiating to the jaw) and its lack of response to typical cardiac treatments (nitroglycerin, opiates), an esophageal cause is plausible. The pain's characteristics and the negative cardiac workup (ECG, chest x-ray, CTA) support this diagnosis.
Other Likely Diagnoses
- Gastroesophageal Reflux Disease (GERD): Similar to esophageal spasm, GERD can cause chest pain that mimics cardiac issues but doesn't respond to cardiac treatments. The radiation to the jaw and the negative cardiac tests make GERD a consideration.
- Costochondritis: Inflammation of the cartilage that connects the ribs to the sternum can cause sharp pains that might radiate and could be exacerbated by movement or deep breathing, fitting the description of pain not alleviated by typical cardiac or pain medications.
- Musculoskeletal Pain: Strain or injury to the muscles or bones in the chest wall could cause pain that radiates to the jaw, especially if the pain is related to movement or position.
Do Not Miss Diagnoses
- Aortic Dissection: Although the CTA was negative, it's crucial to consider aortic dissection due to its high mortality rate if missed. The history of hypertension increases the risk, and some cases might not be immediately apparent on initial imaging.
- Pulmonary Embolism: Despite the negative CTA, pulmonary embolism is a condition that requires careful consideration due to its potential for severe consequences if not treated promptly. However, the presentation would typically include respiratory symptoms or signs of right heart strain.
- Cardiac Causes (e.g., Myocardial Bridge, Coronary Artery Spasm): While the ECG and cardiac imaging were negative, atypical cardiac causes could still be considered, especially given the patient's history of hypertension.
Rare Diagnoses
- Pericarditis: Inflammation of the pericardium can cause chest pain that might radiate to the jaw and is not typically relieved by nitroglycerin or opiates. However, it often presents with a characteristic pericardial friction rub and might show specific findings on ECG or cardiac imaging.
- Thoracic Outlet Syndrome: Compression of the nerves or blood vessels between the collarbone and first rib can cause pain in the chest and jaw, among other symptoms. It's less common and might not be immediately considered but should be kept in mind for persistent, unexplained pain.