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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?

A patient with chest pain poses one of the most complicated diagnostic challenges. The differential diagnosis is enormous and includes diagnoses that can be imminently life-threatening if missed. The main pivotal points when considering a history of chest pain is the acuity of onset of the pain and whether or not the pain is pleuritic (worsening with inspiration). The differential diagnosis of chest pain is the model for an anatomic approach to diagnosis. Consideration needs to be given to the structures from the skin to the internal organs. The differential below is organized anatomically.

  1. Skin: Herpes zoster

  2. Breast

    1. Fibroadenomas

    1. Gynecomastia

  3. Musculoskeletal

    1. Costochondritis

    1. Precordial catch syndrome

    1. Pectoral muscle strain

    1. Rib fracture

    1. Cervical or thoracic spondylosis (C4 - T6)

    1. Myositis

  4. Esophageal

    1. Spasm

    1. Esophagitis

      1. Reflux

      1. Medication-related

    1. Neoplasm

  5. GI

    1. Peptic ulcer disease

    1. Gallbladder disease

    1. Liver abscess

    1. Subdiaphragmatic abscess

    1. Pancreatitis

  6. Pulmonary

    1. Pleura

      1. Pleural effusion

      1. Pneumonia

      1. Neoplasm

      1. Viral infections

      1. Pneumothorax

    1. Lung

      1. Neoplasm

      1. Pneumonia

    1. Pulmonary vasculature

      1. Pulmonary embolism (PE)

      1. Pulmonary hypertension

  7. Cardiac

    1. Pericarditis

    1. Myocarditis

    1. Myocardial ischemia (stable angina, myocardial infarction [MI] or unstable angina)

  8. Vascular: Thoracic aortic aneurysm or aortic dissection

  9. Mediastinal structures

    1. Lymphoma

    1. Thymoma

  10. Psychiatric

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Mr. W comes in regularly for management of hypertension and diabetes, both of which are under good control. He has been having symptoms since just after his last visit 4 months ago. 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?

Mr. W is a middle-aged man with risk factors for coronary artery disease (CAD), whose 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, radiation to back) and thus should be considered. The chronicity of the symptoms argues against many other worrisome diagnoses (eg, PE, pneumothorax, pericarditis, or aortic dissection). Pain from a mediastinal abnormality is possible. Table 8–1 lists the differential diagnosis.

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Physical exam is entirely unremarkable except for mild, stable peripheral neuropathy presumably related to diabetes. ...

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