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Mr. W is a 56-year-old man who comes to your office with chest pain.

image What is the differential diagnosis of chest pain? How would you frame the differential?


Figure 9-1.

Diagnostic approach to chronic chest pain.

A patient with chest pain poses one of the most complicated diagnostic challenges. The differential diagnosis is extensive and includes several life-threatening, time-critical, must not miss diagnoses. The differential is best remembered anatomically, giving consideration to structures from the skin to the internal organs, including:

  1. Skin: Herpes zoster

  2. Breast

    1. Fibroadenomas

    2. Mastitis

    3. Gynecomastia

  3. Musculoskeletal

    1. Costochondritis

    2. Precordial catch syndrome

    3. Tietze syndrome

    4. Pectoral muscle strain

    5. Rib fracture

    6. Cervical or thoracic spondylosis (C4–T6)

    7. Myositis

  4. Esophageal

    1. Spasm

    2. Rupture

    3. Gastroesophageal reflux disease (GERD)

    4. Esophagitis

    5. Neoplasm

  5. Gastrointestinal (GI)

    1. Peptic ulcer disease

    2. Gallbladder disease

    3. Liver abscess

    4. Subdiaphragmatic abscess

    5. Pancreatitis

  6. Pulmonary

    1. Pleura

      1. Pleural effusion

      2. Pneumonia

      3. Neoplasm

      4. Viral infections

      5. Pneumothorax

    2. Lung parenchyma and vasculature

      1. Neoplasm

      2. Pneumonia

      3. Pulmonary embolism (PE)

  7. Cardiac

    1. Acute coronary syndrome (ACS) (unstable angina [UA], myocardial infarction [MI])

    2. Pericarditis

    3. Myocarditis

    4. Stable angina

  8. Vascular: acute aortic syndrome (AAS) (thoracic aortic dissection, intramural hematoma, or aneurysm)

  9. Mediastinal structures

    1. Lymphoma

    2. Thymoma

  10. Psychiatric

Though strict algorithmic approaches toward chest pain often prove intractable in real-world clinical settings, Figures 9-1 and 9-2 are useful for organizing an evaluation. This approach intentionally emphasizes the 3 must not miss diagnoses—ACS, PE, AAS—while avoiding the cognitive bias of “playing the odds,” favoring the common benign, rather than the uncommon serious, diagnoses.

Figure 9-2.

Diagnostic approach to acute chest pain.

The initial pivotal points in the evaluation of chest pain are the duration of symptoms and the patient’s vital signs. Patients with normal vital signs and subacute or chronic chest pain usually seek medical attention in primary care setting while those with acute pain and vital sign abnormalities more commonly go to the emergency department. The presence of coronary heart disease (CHD) risk factors, ECG or chest film abnormalities, symptoms consistent with aortic dissection, or PE risk factors are also important pivotal points.


Mr. W has a history of well-controlled hypertension and diabetes mellitus. 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. Vital signs are temperature, 37.0°C; BP 128/70 mm/Hg; Pulse 72, BPM; RR 16, breaths per minute.

image 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 ...

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