CHEST PAIN

Question 1

60 yo M presents with sudden onset
of substernal heavy chest pain that has
lasted for 30 minutes and radiates to
the left arm. The pain is accompanied
by dyspnea, diaphoresis, and nausea.
He has a history of hypertension,
hyperlipidemia, and smoking.

Answer 1

Myocardial infarction (MI) ECG
GERD CPK-MB, troponin
Angina CXR
Costochondritis CBC, electrolytes
Aortic dissection Echocardiography
Pericarditis Cardiac catheterization
Pulmonary embolism
Pneumothorax

Question 2

20 yo African-American F presents with
acute onset of severe chest pain. She
has a history of sickle cell disease and
multiple previous hospitalizations for
pain and anemia management.

Answer 2

Sickle cell disease— CBC, reticulocyte count, LDH, peripheral smear
pulmonary infarction ABG
Pneumonia CXR
Pulmonary embolism CPK-MB, troponin
MI ECG
Pneumothorax CT—chest with IV contrast
Aortic dissection

Question 3

45 yo F presents with a retrosternal
burning sensation that occurs after
heavy meals and when lying down. Her
symptoms are relieved by antacids.

Answer 3

GERD ECG
Esophagitis Barium swallow
Peptic ulcer disease Upper endoscopy
Esophageal spasm Esophageal pH monitoring
MI
Angina

Question 4

55 yo M presents with retrosternal
squeezing pain that lasts for two minutes
and occurs with exercise. It is relieved by
rest and is not related to food intake.

Answer 4

Angina
Esophageal spasm
Esophagitis
ECG
CPK-MB, troponin
CXR
CBC, electrolytes
Exercise stress test
Upper endoscopy/pH monitor
Cardiac catheterization

Question 5

34 yo F presents with retrosternal
stabbing chest pain that improves when
she leans forward and worsens with deep
inspiration. She had a URI one week
ago.

Answer 5

Pericarditis ECG
Aortic dissection CPK-MB, troponin
MI CXR
Costochondritis Echocardiography
GERD CBC
Esophageal rupture Upper endoscopy

Question 6

34 yo F presents with stabbing chest pain
that worsens with deep inspiration and is
relieved by aspirin. She had a URI one
week ago. Chest wall tenderness is noted.

Answer 6

Costochondritis ECG
Pneumonia CPK-MB, troponin
MI CXR
Pulmonary embolism CBC
Pericarditis
Muscle strain

Question 7

70 yo F presents with acute onset of
shortness of breath at rest and pleuritic
chest pain. She also presents with
tachycardia, hypotension, tachypnea,
and mild fever. She is recovering from
hip replacement surgery.

Answer 7

Pulmonary embolism ECG
Pneumonia CXR
Costochondritis ABG
MI CPK-MB, troponin
CHF CBC, electrolytes
Aortic dissection CT—chest with IV contrast
CXR
D-dimer

Question 8

55 yo M presents with sudden onset of
severe chest pain that radiates to the
back. He has a history of uncontrolled
hypertension.

Answer 8

Aortic dissection ECG, CPK-MB, troponin
MI CXR
Pericarditis CBC, amylase, lipase
Esophageal rupture Transesophageal
Esophageal spasm echocardiography (TEE),
GERD MRI/MRA—aorta
Pancreatitis Aortic angiography
Fat embolism Upper endoscopy