A 55-year-old man with a history of gastroesophageal reflux disease presents to the emergency department with sudden-onset, severe substernal chest pain. He reports the pain radiates to his left jaw and is accompanied by profuse sweating and nausea. He took his prescribed antacid at home 30 minutes ago without relief. An initial electrocardiogram shows normal sinus rhythm without acute ST-segment changes, and a point-of-care troponin level is within normal limits. Despite these initial test results, which of the following conditions must remain the highest priority in the differential diagnosis?
- Acute coronary syndromeAnswer
- BDiffuse esophageal spasm
- CAcute aortic dissection
- DCostochondritis
- EPeptic ulcer perforation
Answer
Acute coronary syndrome
The correct answer is acute coronary syndrome. The patient presents with classic features of cardiac ischemia, including substernal chest pain radiating to the jaw, accompanied by diaphoresis and nausea. A key principle in formulating a differential diagnosis is that an initial electrocardiogram and troponin level can be normal in the early stages of acute coronary syndrome (such as unstable angina or early non-ST-segment elevation myocardial infarction). Therefore, life-threatening conditions with high pre-test probability based on classic symptoms must not be prematurely removed from the differential diagnosis.
Step-by-Step Solution
Key Concept
Formulating a differential diagnosis based on high pre-test probability and recognizing the limitations of early diagnostic testing in acute presentations.