Differential Diagnoses


Differential Diagnosis #1

  • Myocardial Infarction (MI)

Rationale:

  • Patient is experiencing severe chest pain which radiates to the back, restlessness, and malaise. Patients experiencing acute MI’s commonly have pain which radiates to the back, arms, or jaw.
    • Angina related to MI’s is typically more of a sudden onset, lasting minutes or hours, not multiple days long like the patient has been experiencing.
    • However, patient experiences worsening of chest pain during respirations, which is not common with MI’s, but is common with pericarditis.
  • Patient has ECG abnormalities, which occur with an acute MI.
    • Acute MI’s present with a presence of Q waves, the patient has an absence of Q waves.
    • The patient has concave ST segment, which is a common presentation in pericarditis. Patients with MI’s have convex ST segments.
    •  The EKG shows PR depression, which is absent in MI, and is present in pericarditis.

The left segment represents acute pericarditis, the middle segment represents early repolarization, and the right segment represents acute MI. In acute pericarditis (left), we can see the ST  segment is concave upward , whereas in acute MI (right), displays a convex upward ST segment. Additionally, in acute pericarditis (left), there is a lack of Q waves. In contrast, in acute MI (right), Q waves are present. In pericarditis (left), we also see PR depression, which is absent in MI (right). (Marinella, 1998).

 

 

 

 

 

 

 

 

 

Differential Diagnosis #2

  • Pulmonary Embolism

Rationale:

  • Patient is experiencing severe anterior chest pain that worsens with respiratory effort. Patient also complains of anxiety and malaise.
    • However, angina related to a pulmonary embolism can be posterior or lateral, it doesn’t depend on posture, and pain does not occur when patient ceases breathing. Pleural chest pain with a pulmonary embolism can be felt more laterally compared to cardiac chest pain with pericarditis, which is always central.
  • Upon examination, the patient is experiencing sinus tachycardia and a friction rub is detected.
    • Pleural friction rubs, which may occur with a pulmonary embolism, can only be heard during inspiration and expiration, whereas, pericardial friction rubs can be heard even when the patient is not breathing in the case of pericarditis.
  • ECG abnormalities can also distinguish a pulmonary embolism from pericarditis.
    • For Pericarditis, changes may reflect inflammatory processes through PR-segment depression and diffuse ST-segment elevation without Q waves.
    • For Pulmonary Embolisms, there are no PR-segment depressions and T-waves are inverted.

Differential Diagnosis #3

  • Pneumothorax

Rationale:

  • The patient has many symptoms that overlap with pericarditis including shortness of breath and chest pain.
  • ECG findings can be used to differentiate between pericarditis and a pneumothorax
    • A pneumothorax will also reveal ECG abnormalities in

      (Shiyovich, Zeldetz & Lior, 2011).

      cluding a reduced R -wave amplitude, QRS depression and T-wave inversions. (Shown in lead two on right)

    • Findings of pericarditis are as mentioned above (ST-segment elevation, PR segment depression and down sloping of TP segment)
  • Although both diseases can cause chest pain, pericarditis may result in more positional chest pain which is worse while lying down or inspiration. Chest pain experienced due to a pnuemothorax is not dependent on position, sharp and stabbing in natures and usually presents unilaterally.
  • Upon examination, both diseases can result in tachycardia, however breath sounds will be absent in one lung if the patient is suffering from a pnuemothorax and can also result in a tracheal deviation away from the side of the collapsed lung.
    • Pericarditis will have breath sounds in both lungs, however abnormal findings could be pleural effusion or a friction rub while auscultating the lungs