What is the differential diagnosis and management plan for a 21-year-old female with multiple episodes of vomiting, low-grade fever, and central chest pain that radiates up and down?

Differential Diagnosis and Management for 21-Year-Old Female with Vomiting, Low-Grade Fever, and Central Chest Pain

Immediate Priority: Exclude Life-Threatening Cardiac and Thoracic Emergencies

This patient requires immediate 12-lead ECG within 10 minutes and cardiac troponin measurement to exclude acute coronary syndrome, followed by urgent evaluation for esophageal perforation (Boerhaave syndrome), which is the most critical diagnosis to rule out given chest pain following vomiting. 1, 2

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Differential Diagnosis (Prioritized by Urgency)

Life-Threatening Conditions (Immediate Evaluation Required)

1. Boerhaave Syndrome (Esophageal Rupture)

• Most critical diagnosis in any patient with chest pain following forceful vomiting 2
• Presents with sudden severe central chest pain radiating up and down after vomiting episodes 2
• Can be accompanied by low-grade fever, nausea, and hemodynamic stability initially 2
• Requires immediate chest X-ray looking for surgical emphysema, pneumomediastinum, or pleural effusion 2
• If suspected, obtain contrast-enhanced CT chest urgently to confirm esophageal rupture 2

2. Acute Coronary Syndrome

• Must be excluded first despite young age, as women can present with atypical symptoms including nausea and vomiting 1
• Central chest pain with nausea and vomiting are classic associated symptoms of cardiac ischemia 1
• Obtain 12-lead ECG within 10 minutes of presentation 1
• Measure cardiac troponin immediately 1
• Women aged 30-39 have 26% likelihood of coronary disease with typical angina symptoms 1

3. Pulmonary Embolism

• Can present with pleuritic chest pain, low-grade fever, and vomiting 1, 3
• May mimic infectious pleuritis and be misdiagnosed 3
• Consider in young women, especially with risk factors (oral contraceptives, immobility) 3

4. Aortic Dissection

• Severe chest pain radiating up and down is characteristic 1
• Accompanied by nausea, vomiting, and diaphoresis 1
• Check blood pressure in both arms (>15 mmHg difference suggests dissection) 1

5. Pneumothorax

• Sudden onset chest pain with dyspnea 1
• Requires immediate chest X-ray 1

Non-Life-Threatening but Urgent Conditions

6. Medication-Induced Esophageal Injury (Pill Esophagitis)

• If patient recently took antibiotics (especially doxycycline, amoxicillin/clavulanate) or NSAIDs 4
• Presents with severe odynophagia and chest pain after medication use 4
• Requires urgent upper endoscopy within 2 weeks if alarm symptoms present 4

7. Acute Gastroenteritis with Severe GERD/Esophagitis

• Vomiting can cause esophageal inflammation and chest pain 1, 5
• Low-grade fever supports infectious etiology 5
• Central chest pain may represent severe reflux or esophagitis 1

8. Peptic Ulcer Disease or Gastritis

• Can present with epigastric/central chest pain, nausea, and vomiting 1
• May have low-grade fever if complicated by perforation 1

9. Pancreatitis

• Central/epigastric pain radiating to back, with nausea and vomiting 6
• Check serum lipase 6

10. Myocarditis (Post-Viral)

• Can present with chest pain, fever, and vomiting 4
• Troponin may be elevated 4

11. Costochondritis or Musculoskeletal Pain

• Chest wall pain that varies with position or palpation 1
• Pain localized and reproducible on examination 1

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Immediate Management Algorithm

Step 1: Rapid Triage and Vital Signs Assessment (First 5 Minutes)

• Obtain vital signs immediately: blood pressure (both arms), heart rate, respiratory rate, oxygen saturation, temperature 1
• Assess hemodynamic stability: signs of shock (cool, clammy skin, hypotension, tachycardia) 1
• Place patient on continuous cardiac monitoring with defibrillation capability 1
• Establish IV access 1

Step 2: Immediate Cardiac Exclusion (Within 10 Minutes)

Obtain 12-lead ECG within 10 minutes 1

• Look for ST-segment elevation, depression, T-wave inversions, or S1Q3T3 pattern (suggests PE) 1, 3
• If ST-elevation present, activate STEMI protocol immediately 1

Administer aspirin 160-325 mg immediately (chewable or water-soluble) unless contraindicated 1

Measure cardiac troponin stat 1, 4

If ECG shows ischemic changes or troponin elevated:

• Administer sublingual nitroglycerin (unless bradycardia or hypotension present) 1
• Give morphine IV if pain not relieved by nitroglycerin 1
• Urgent cardiology consultation 1

Step 3: Evaluate for Esophageal Perforation (Within 30 Minutes)

Given chest pain following vomiting, Boerhaave syndrome must be excluded urgently 2

Obtain portable chest X-ray immediately (within 30 minutes) 1, 2

• Look for: pneumomediastinum, surgical emphysema, pleural effusion, pneumothorax 2

If chest X-ray shows any concerning findings:

• Obtain contrast-enhanced CT chest immediately to confirm esophageal rupture 2
• NPO (nothing by mouth) immediately 2
• Broad-spectrum IV antibiotics (cover oral flora and anaerobes) 2
• Urgent cardiothoracic surgery consultation 2

Step 4: Initial Laboratory Workup

Obtain immediately: 5, 6

• Complete blood count (assess infection, inflammation) 6
• Serum electrolytes and glucose (assess dehydration, metabolic alkalosis from vomiting) 5, 6
• Liver function tests 6
• Serum lipase (exclude pancreatitis) 6
• Urinalysis (assess hydration, rule out pregnancy) 6
• Urine or serum pregnancy test (mandatory in all women of childbearing age)

Consider if clinically indicated: 5

• Urine drug screen (cannabis hyperemesis syndrome in this age group) 5
• D-dimer if PE suspected 3

Step 5: Symptomatic Management While Awaiting Results

Fluid Resuscitation:

• Administer isotonic IV fluids (lactated Ringer's or normal saline) for dehydration 5
• Monitor urine output 6

Antiemetic Therapy (if cardiac causes excluded): 5, 6

• Ondansetron 8 mg IV/sublingual every 4-6 hours (first-line) 5, 6
• Alternative: Prochlorperazine 5-10 mg IV every 6-8 hours 6
• Alternative: Promethazine 12.5-25 mg IV every 4-6 hours 6
• Monitor ECG for QTc prolongation with ondansetron 5, 6

Pain Management (if cardiac causes excluded):

• Avoid NSAIDs if esophageal injury suspected 4
• Consider acetaminophen or opioids if severe 1

Gastric Protection:

• Proton pump inhibitor IV (esomeprazole 40 mg or pantoprazole 40 mg) 4

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Disposition Algorithm Based on Initial Workup

If Cardiac Workup Positive (ST-elevation, troponin elevation, ischemic ECG changes):

• Activate acute coronary syndrome protocol 1
• Immediate cardiology consultation 1
• Admit to cardiac care unit 1

If Esophageal Perforation Confirmed:

• Immediate cardiothoracic surgery consultation 2
• NPO, IV antibiotics, IV fluids 2
• Admit to surgical ICU 2

If Both Cardiac and Esophageal Perforation Excluded:

Assess for other urgent conditions:

If severe dehydration, inability to tolerate oral intake, or electrolyte abnormalities:

• Admit for IV hydration and electrolyte correction 5, 6
• Continue antiemetics scheduled (not PRN) 5
• Thiamine 200-300 mg daily to prevent Wernicke's encephalopathy 5, 6

If hemodynamically stable and tolerating oral intake:

• Arrange urgent GI consultation for upper endoscopy within 2-7 days if alarm symptoms present (severe odynophagia, weight loss, persistent symptoms) 4
• Discharge with:
  • Oral antiemetics (ondansetron 8 mg every 6-8 hours) 6
  • Proton pump inhibitor (esomeprazole 40 mg daily) 4
  • Liquid or soft diet 4
  • Strict return precautions for worsening chest pain, dyspnea, hematemesis, or inability to tolerate oral intake 2

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Critical Pitfalls to Avoid

1. Never assume "just gastroenteritis" in a young patient with chest pain and vomiting 2

• Boerhaave syndrome is rapidly fatal if missed 2
• Always obtain chest X-ray if chest pain follows vomiting 2

2. Do not dismiss cardiac causes based on age alone 1

• Women present with atypical symptoms more frequently than men 1
• Nausea and vomiting are common cardiac symptoms in women 1

3. Never give antiemetics if mechanical bowel obstruction suspected 5

• Can mask progressive ileus and gastric distension 5

4. Do not delay endoscopy if alarm symptoms present 4

• Odynophagia, weight loss, or persistent symptoms require urgent evaluation 4
• Delaying risks missing malignancy, stricture, or perforation 4

5. Monitor for QTc prolongation with ondansetron 5, 6

• Obtain baseline ECG before administration 6
• Avoid in combination with other QT-prolonging agents 5

6. Consider cannabis hyperemesis syndrome in this age group 5

• Take detailed cannabis use history 5
• Hot showers providing relief is pathognomonic 5

7. Correct electrolyte abnormalities aggressively 5

• Prolonged vomiting causes hypokalemia, hypochloremia, metabolic alkalosis 5
• Check and replace magnesium (required for potassium repletion) 5