Differential Diagnosis for Chest Pain
The patient presents with episodic chest pain that lasts for approximately 60 minutes, with the pain gradually increasing and then reducing, only to return again. The pain is localized to the chest bone and is also felt at the same level on the spine in the back. Given the normal EKG, blood pressure, and heart rate, along with a heart rate variability (HRV) of 30 measured by Whoop, the following differential diagnoses are considered:
Single Most Likely Diagnosis
- Costochondritis: This condition, which involves inflammation of the cartilage that connects the ribs to the breastbone, can cause sharp pains or aches in the chest. The pain can be exacerbated by movement or deep breathing and can radiate to the back, matching the patient's symptoms. The episodic nature and the specific location of the pain at the chest bone and the corresponding level on the spine support this diagnosis.
Other Likely Diagnoses
- Musculoskeletal Pain: Given the patient's fit condition and the nature of the pain, musculoskeletal issues such as strained muscles in the chest or back could be a cause. The pain's location and the fact that it does not radiate could suggest a localized musculoskeletal issue.
- Gastroesophageal Reflux Disease (GERD): Although the pain does not radiate, GERD can cause chest pain that may be perceived as originating from the chest bone. The episodic nature could be related to eating or lying down after meals.
- Stress or Anxiety: The patient's HRV of 30, which is on the lower side, could indicate stress or anxiety. These conditions can manifest as chest pain or discomfort, especially in individuals who are otherwise fit and healthy.
Do Not Miss Diagnoses
- Acute Coronary Syndrome (ACS): Although the EKG is normal and the patient is young and fit, ACS (including myocardial infarction) must be considered, especially if the pain is severe or accompanied by other symptoms like shortness of breath or nausea. The lack of radiation and normal initial EKG does not rule out ACS entirely.
- Pulmonary Embolism (PE): This is a life-threatening condition that can cause chest pain, often described as sharp and stabbing, which can worsen with deep breathing. The absence of other typical symptoms (e.g., shortness of breath, cough) does not exclude PE.
- Aortic Dissection: A severe, tearing chest pain that can radiate to the back is characteristic of an aortic dissection. Although the patient's pain does not radiate in the classic manner, any chest pain that could potentially be related to the aorta must be thoroughly investigated.
Rare Diagnoses
- Tietze's Syndrome: Similar to costochondritis but involves the inflammation of the cartilages and surrounding tissues of the upper ribs. It's less common and could be considered if costochondritis is ruled out.
- Spinal Issues: Certain spinal conditions, such as a herniated disk or spinal stenosis at the thoracic level, could potentially cause referred pain to the chest area, although this would be less common and typically accompanied by other neurological symptoms.
- Pericarditis: Inflammation of the pericardium, the sac surrounding the heart, can cause chest pain that may improve with sitting up and leaning forward. It's a less common condition but should be considered in the differential diagnosis of chest pain.