Differentials
Acute coronary syndrome
SIGNS / SYMPTOMS
Severe chest pain-associated dyspnea, nausea, and diaphoresis. The chest pain may be intermittent and precipitated by exertion.
Risk factors for cardiovascular disease (e.g., family history, hypertension, hyperlipidemia, diabetes, and smoking) are usually present.
INVESTIGATIONS
ECG may reveal ST elevation and cardiac enzymes may be elevated.
Pleuritis
SIGNS / SYMPTOMS
Associated dyspnea and shortness of breath.
Decreased breath sounds on auscultation and dullness on percussion.
INVESTIGATIONS
Chest x-ray may show an effusion.
Pulmonary embolism
SIGNS / SYMPTOMS
Risk factors for thromboembolic disease (e.g., family history, smoking, oral contraceptive pill use, prolonged immobilization, or limb trauma).
Associated dyspnea. Hemoptysis may be present. Physical exam may reveal signs of right ventricular dysfunction (e.g., distended neck veins, systolic murmur over left lower sternal edge, loud pulmonary component of S2).[17]
INVESTIGATIONS
Elevated d-dimer.
CT pulmonary angiogram showing arterial clot or perfusion/ventilation scan showing mismatch.
Rib fracture
SIGNS / SYMPTOMS
History of trauma and tenderness over the rib.
INVESTIGATIONS
Rib fracture visible on rib view plain x-rays.
Sternal or clavicular fracture
SIGNS / SYMPTOMS
History of trauma, tenderness over sternum or clavicle.
INVESTIGATIONS
Clavicular or sternal fracture visible on plain x-rays.
Pneumothorax
Gastroesophageal reflux disease
SIGNS / SYMPTOMS
Symptoms of heartburn and regurgitation.
INVESTIGATIONS
An 8-week therapeutic trial of proton pump inhibitor may produce improvement.[19]
Panic disorder
Generalized anxiety disorder
SIGNS / SYMPTOMS
History of worry present most of the time for >6 months.
May have a family history of anxiety.[22]
INVESTIGATIONS
Clinical diagnosis requiring formal psychiatric assessment.
Depression
SIGNS / SYMPTOMS
Lack of interest in activities and depressed affect for >2 months, insomnia, feelings of worthlessness, excessive guilt, fatigue, poor concentration, and suicidal ideation.[23]
INVESTIGATIONS
Clinical diagnosis requiring formal psychiatric assessment.
Underlying malignancy
Seronegative spondyloarthropathies
SIGNS / SYMPTOMS
Associated conditions such as psoriasis, inflammatory bowel disease, or sexually transmitted disease.
Insidious onset of low-back pain, worse in the morning or after rest. The pain lasts ≥30 minutes and improves with activity.
Sacroiliitis may present with bilateral or unilateral buttock pain radiating to the thigh.
Physical exam may reveal peripheral inflammatory arthritis, limitation of lumbar spine movement in frontal and sagittal planes, decreased chest expansion, and anterior uveitis.[26]
INVESTIGATIONS
Sacroiliac joint x-ray showing indistinct joints, bony erosions, sclerosis, and widening of the joint space.
Spinal x-ray showing marginal vertebral body erosions, vertebral body squaring, and syndesmophytes between vertebrae.[26]
Radiographic evidence of peripheral erosive arthritis, especially in the case of psoriatic arthritis.
Disease specific evaluation, such as dermatology consultation for psoriasis, gastroenterological evaluation, and colonoscopy and/or endoscopy for inflammatory bowel disease.
Fibromyalgia
SIGNS / SYMPTOMS
Widespread body pain.
More than 11 of 18 defined tender points are tender upon palpation.[27]
INVESTIGATIONS
Clinical diagnosis.
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