Chest pain

Question 1

Key history in chest pain

Answer 1

Location
Quality
Severity
Radiation
Duration
Context (exertional, postprandial, positional, cocaine use, trauma)
Other symptoms (sweating, nausea, dyspnea, palpitations, sense of doom, fever)
Exacerbating and alleviating factors (especially medications)
Hx of similar symptoms
Known heart or lung disease
Cardiac risk factors (HTN, HLD, smoking, FHx of early MI)
Pulmonary embolism risk factors (Hx of DVT, coagulopathy, malignancy, recent immobilization)

Question 2

Key physical exam in chest pain

Answer 2

Vital signs with BP in both arms
Complete CV exam (JVD, PMI, chest wall tenderness, heart sounds, pulses, edema)
Lung and abdominal exams
Lower extremity exam (inspection for signs of DVT)

Question 3

60 yo M with sudden onset substernal heavy chest pain lasting 30 minutes
+ radiates to left arm
+ dyspnea, diaphoresis, nausea
+ HTN, HLD and smoking

Answer 3

Acute MI
GERD
Angina
Pulmonary embolism

ECG, CPK-MB, troponin x 3, CXR, CBC, electrolytes, electrocardiography, cardiac catheterization, d-dimer, helical CT (for PE)

Question 4

20 yo African American F with acute onset severe chest pain over last few hours
+ Sickle cell disease
+ Prior episodes

Answer 4

Acute chest syndrome
Pulmonary embolism
Acute MI

CBC with reticulocyte count and peripheral smear, LDH, ABG, d-dimer, CXR, CPK-MB, troponin, ECG, CTA - chest with IV contrast

Question 5

45 yo F with retrosternal burning sensation after heavy meals and when lying down
+ relieved by antacids

Answer 5

GERD
Esophagitis
Peptic ulcer disease
MI
Angina

ECG, barium swallow, upper endoscopy, esophageal pH monitoring

Question 6

55 yo M with retrosternal squeezing pain lasting two minutes with exercise
+ relieved by rest and not related to food intake

Answer 6

Stable angina
Esophageal spasm
Esophagitis

ECG, CPK-MB, troponin, CXR, CBC, electrolytes, exercise stress test, upper endoscopy/pH monitoring, cardiac catheterization

Question 7

34 yo F with retrosternal stabbing chest pain
+ improves when leaning forward and worsens with deep inspiration
+ URI one week ago

Answer 7

Pericarditis
Aortic dissection
MI
GERD

ECG, CPK-MB, troponin, CXR, CBC, d-dimer, echocardiograpy, upper endoscopy, ESR

Question 8

33 yo F with stabbing chest pain worse with deep inspiration and relieved by aspirin
+ URI one week ago
+ chest wall tenderness noted

Answer 8

Costochondritis
Pneumonia
MI
Pericarditis
Pulmonary embolism

ECG, CPK-MB, troponin, CXR, CBC

Question 9

70 yo F with acute onset SOB at rest and pleuritic chest pain
+ tachycardia, hypotension, tachypnea and mild fever
+ recent immobility

Answer 9

Pulmonary embolism
Pneumonia
Costochondritis
MI

D-dimer, ECG, CXR, ABG, CPK-MB, troponin, CBC, electrolytes, BUN/Cr, glucose, CTA - chest with IV contrast, Doppler US - legs

Question 10

55 yo with sudden onset severe chest pain radiating to back

+ uncontrolled HTN

Answer 10

Aortic dissection
MI
Esophageal rupture
Pancreatitis

ECG, CPK-MB, troponin, CXR, CBC, amylase, lipase, CTA - chest with IV contrast, transesophageal echocardiography (TEE), MRI/MRA - aorta, aortic angiography, upper endoscopy