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PATIENT 
Mr. W is a 56-year-old man who comes to your office with chest pain.
What is the differential diagnosis of chest pain? How would you frame the differential?
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CONSTRUCTING A DIFFERENTIAL DIAGNOSIS
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A patient with chest pain poses one of the most complicated diagnostic challenges. The differential diagnosis is extensive and includes diagnoses that can be imminently life-threatening. The initial pivotal points are the acuity of onset of the pain and the presence of vital sign abnormalities. Later in the evaluation, the presence of ECG or chest film abnormalities, symptoms consistent with aortic dissection, and the presence or absence of pleuritic pain (pain that worsens with inspiration) are important pivotal points. An algorithm to guide the consideration of the patient with chest pain is shown in Figure 9-1.
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The differential diagnosis of chest pain is best remembered using an anatomic approach. Consideration needs to be given to the structures from the skin to the internal organs. The differential below is organized anatomically.
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Skin: Herpes zoster
Breast
Fibroadenomas
Mastitis
Gynecomastia
Musculoskeletal
Costochondritis
Precordial catch syndrome
Pectoral muscle strain
Rib fracture
Cervical or thoracic spondylosis (C4–T6)
Myositis
Esophageal
Spasm
Rupture
Esophagitis
Reflux
Medication-related
Neoplasm
Gastrointestinal (GI)
Peptic ulcer disease
Gallbladder disease
Liver abscess
Subdiaphragmatic abscess
Pancreatitis
Pulmonary
Pleura
Pleural effusion
Pneumonia
Neoplasm
Viral infections
Pneumothorax
Lung
Neoplasm
Pneumonia
Pulmonary vasculature
Pulmonary embolism
Pulmonary hypertension
Cardiac
Pericarditis
Myocarditis
Myocardial ischemia (stable angina, myocardial infarction, or unstable angina)
Vascular: Thoracic aortic aneurysm or aortic dissection
Mediastinal structures
Lymphoma
Thymoma
Psychiatric
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Mr. W has a history of well-controlled hypertension and diabetes. He has been having symptoms for the last 4 months. He feels squeezing, substernal pressure while climbing stairs to the elevated train he rides to work. The pressure resolves after about 5 minutes of rest. He also occasionally feels the sensation during stressful periods at work. It is occasionally associated with mild nausea and jaw pain. Medications are metformin, aspirin, and enalapril.
At this point, what is the leading hypothesis, what are the active alternatives, and is there a must not miss diagnosis? Given this differential diagnosis, what tests should be ordered?
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RANKING THE DIFFERENTIAL DIAGNOSIS
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Mr. W is a middle-aged man with chronic, nonpleuritic chest pain and risk factors for coronary artery disease (CAD). His symptoms are consistent with stable angina. The pivotal points in this case are the chronicity, exertional nature, and substernal location of the pain. Given the seriousness and prevalence of CAD, it must lead the differential diagnosis. Gastroesophageal reflux disease (GERD) and musculoskeletal disorders are common causes of chest pain that can mimic angina (exacerbated by activity, sensation of pressure) and thus should be considered. The chronicity of his symptoms ...