CASE 1 - Chest Pain

Question 1

Is this a heart attack? Am I going to die?

Answer 1

As you suspect, your symptoms are of significant concern.

We need to learn more about what’s going on to know if your pain is life threatening.

Question 2

Specific questions about the chest pain:

Answer 2

1. Shortness of breath, cough, wheezing.
2. Sweating.
3. Nausea/vomiting.
4. Previous episodes of similar pain.
5. Cocaine/alcohol.

Question 3

PEx:

5

Answer 3

1. NECK ==> JVD, carotid auscultation.
2. CV ==> Inspection, auscultation, palpation.
3. Pulmonary ==> Auscultation, palpation, percussion.
4. Abdominal ==> Auscultation, palpation, percussion.
5. Extremities ==> Check peripheral pulses — checked BP in BOTH arms — looked for edema + cyanosis.

Question 4

Closure should include:

3

Answer 4

1. Discuss initial diagnostic impressions.
2. Discuss initial management plants — follow-up tests and lifestyle modification (diet, exercise).
3. Examinee asked if the SP had any other questions or concerns.

Question 5

Sample closure for chest pain:

Answer 5

Mr. Short, the source of your pain can be a cardiac problem such as a heart attack or angina, or it may be due to acid reflux, lung problems, or disorders related to the large blood vessels in your chest.

It is crucial that we perform some tests to identify the source of your problem.

We will start with an ECG and some blood work, but more complex tests may be needed as well.

In the meantime, I strongly recommend that you stop using cocaine, since use of this drug can lead to a variety of medical problems including heart attacks.

Question 6

DDx 1 — Myocardial ischemia or infarction:

Answer 6

Hx:

Pressure-like substernal chest pain.
Pain radiates to left arm, upper back, and neck.
Pain awakens patient at night.

Question 7

DDx 2 — Cocaine-induced myocardial ischemia

Answer 7

Hx:

History of cocaine use.
Last used yesterday afternoon.
Pressure-like substernal chest pain

Question 8

DDx 3 — GERD:

Answer 8

Hx:

Pain in midchest.
Previous pain was relieved by antacids.
Previous pain occurred after heavy meals.

Question 9

Diagnostic workup (5):

Answer 9

1. ECG.
2. Enzymes (CPK, CPK-MB, troponin).
3. Transthoracic echocardiography.
4. Upper endoscopy.
5. Urine toxicology.

Question 10

Additional DDx:

5

Answer 10

1. Aortic dissection.
2. Pericarditis.
3. Pneumothorax.
4. Pulmonary embolism.
5. Costochondritis (or other musculoskeletal chest pain).