Clinical scenarios to diagnose Flashcards
A 65-year-old man, who smokes and has a history of hypertension and peripheral vascular disease, now presents with increasing frequency and severity of chest discomfort over the past week. He reports that he previously had chest pain after walking 100 metres, but now is unable to walk more than 50 metres without developing symptoms. The pain radiates from his chest to the left side of the neck and is only eased after increasing periods of rest.
Unstable angina
- Unstable angina may present without chest pain or with atypical or non-specific symptoms, especially in younger and older populations; female patients; or in the presence of diabetes, dementia, and renal failure.[3][4][5][6] Atypical symptoms include dyspnoea, indigestion, dizziness, syncope (usually related to severe pain), sweating, and weakness.
A 45-year-old woman with type 1 diabetes (diagnosed when she was a teenager) presents to the accident and emergency department with abdominal pain, nausea, and shortness of breath that woke her up from sleep.
Unstable angina
- Unstable angina may present without chest pain or with atypical or non-specific symptoms, especially in younger and older populations; female patients; or in the presence of diabetes, dementia, and renal failure.[3][4][5][6] Atypical symptoms include dyspnoea, indigestion, dizziness, syncope (usually related to severe pain), sweating, and weakness.
A 50-year-old man presents to clinic with a complaint of central chest discomfort of 2 weeks’ duration, occurring after walking for more than 5 minutes or climbing more than one flight of stairs. The chest discomfort resolves with rest within several minutes. He is obese, has a history of hypertension, and smokes 10 cigarettes a day. His father died from a myocardial infarction at the age of 54 years. On examination, his blood pressure is 144/92 mmHg with a heart rate of 82 bpm. The remainder of his examination is normal.
Stable ischaemic heart disease (stable angina)
- Atypical locations of anginal pain include the epigastrium, neck, jaw, or arms. Exertional dyspnoea, fatigue, nausea, indigestion, and light-headedness are alternative symptoms sometimes called anginal equivalents. Women, older people, and patients with diabetes may be more likely to present with atypical angina or anginal equivalents.
A 60-year-old man with a history of a myocardial infarction presents to clinic for follow-up. He was started on aspirin, beta-blocker, and statin therapy after his heart attack. In the past 2 weeks the patient has noted return of chest pressure when he walks rapidly. The chest pressure resolves with sublingual glyceryl trinitrate or a decrease in his activity level. He is a former smoker and has modified his diet and activity to achieve his goal body weight. He is normotensive on examination with a heart rate of 72 bpm. The remainder of his examination is normal.
Stable ischaemic heart disease (stable angina)
- Atypical locations of anginal pain include the epigastrium, neck, jaw, or arms. Exertional dyspnoea, fatigue, nausea, indigestion, and light-headedness are alternative symptoms sometimes called anginal equivalents. Women, older people, and patients with diabetes may be more likely to present with atypical angina or anginal equivalents.
A 54-year-old man with a medical history of hypertension, diabetes, dyslipidaemia, smoking, and family history of premature coronary artery disease presents with retrosternal crushing chest pain (10/10 in intensity), radiating down the left arm and left side of the neck. He feels nauseated and light-headed and is short of breath. Examination reveals hypotension, diaphoresis, and considerable discomfort with diffuse bilateral rales on chest auscultation. ECG reveals convex ST-segment elevation in leads V1 to V6.
STEMI
- Patients with STEMI may also be asymptomatic or present with atypical chest pain or epigastric pain.
A 70-year-old woman is 2 days post-operative for knee replacement surgery. Her past medical history includes type 2 diabetes and a 40 pack-year history of smoking. She reports feeling suddenly unwell with dizziness, nausea, and vomiting. She denies any chest pain. On examination she is hypotensive and diaphoretic. ECG shows convex ST-segment elevation in leads II, III, and aVF with reciprocal ST segment depression and T-wave inversion in leads I and aVL.
STEMI
- Patients with STEMI may also be asymptomatic or present with atypical chest pain or epigastric pain.
A 69-year-old man develops worsening substernal chest pressure after shovelling snow in the morning before work. He tells his wife he feels a squeezing pain that is radiating to his jaw and left shoulder. He appears anxious and his wife calls for an ambulance, as he is distressed and sweating profusely. Past medical history is significant for hypertension and he has been told by his doctor that he has borderline diabetes. On examination in the accident and emergency department he is very anxious and diaphoretic. His heart rate is 112 bpm and blood pressure is 159/93 mmHg. The ECG is significant for ST depression in the anterior leads.
non-stemi
- Presentations of myocardial infarction can be diverse. Some patients do not have any chest discomfort, whereas others may experience classic ‘crushing’ or severe pain. It is important to recognise that atypical presentation such as epigastric pain, indigestion-like symptoms, isolated dyspnoea, or syncope can indicate acute coronary syndrome. These atypical presentations are more common in women, older people, and people with diabetes, chronic kidney disease, or dementia. A feeling of indigestion may be the only symptom and occurs more often with inferior wall myocardial infarction. Highly specific presentations include substernal pressure/discomfort, which may radiate to the arm, neck, and shoulder, associated with diaphoresis.[1] Some patients present with jaw, neck, arm, or epigastric pain only. These symptoms should be considered equivalent to angina if they are clearly related to stress or exertion, or are quickly relieved by physical rest. A sharp, stabbing pain or pain reproducible on palpation does not exclude acute coronary syndrome.[1]
