usmle CS FA minicase8
Terms
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CHEST PAIN
Key History -
Key History
Location, quality, severity, radiation, duration, context (exertional, postprandial, positional, cocaine use,
trauma), associated symptoms (sweating, nausea, dyspnea, palpitation, sense of doom), exacerbating and
alleviating factors (especially medicines); prior history of similar symptoms; known heart or lung disease
or history of diagnostic testing; cardiac risk factors (hypertension, hyperlipidemia, smoking, family history
of early MI); pulmonary embolism risk factors (history of DVT, coagulopathy, malignancy, recent immobilization). -
CHEST PAIN
Key Physical Exam -
Key Physical Exam
Vital signs ± BP in both arms; complete cardiovascular exam (JVD, PMI, chest wall tenderness, heart
sounds, pulses, edema); lung and abdominal exams. -
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,
hy -
D/D:
Myocardial infarction (MI)
GERD
Angina
Costochondritis
Aortic dissection
Pericarditis
Pulmonary embolism
Pneumothorax
W/O:
ECG
CPK-MB, troponin
CXR
CBC, electrolytes
Echocardiography
Cardiac catheterization -
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. -
D/D:
Sickle cell disease—pulmonary
infarction
Pneumonia
Pulmonary embolism
MI
Pneumothorax
Aortic dissection
W/O:
CBC, reticulocyte count, LDH,
peripheral smear
ABG
CXR
CPK-MB, troponin
ECG
V/Q scan
CT—chest with IV contrast -
45 yo F presents with a retrosternal
burning sensation that occurs after heavy
meals and when lying down. Her
symptoms are relieved by antacids. -
D/D:
GERD
Esophagitis
Peptic ulcer disease
Esophageal spasm
MI
Angina
W/O:
ECG
Barium swallow
Upper endoscopy
Esophageal pH monitoring -
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. -
D/D:
Angina
GERD
Esophageal spasm
Esophagitis
W/O:
ECG
CPK-MB, troponin
CXR
CBC, electrolytes
Exercise stress test
Upper endoscopy/pH monitor
Cardiac catheterization -
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. -
D/D:
Pericarditis
Aortic dissection
MI
Costochondritis
GERD
Esophageal rupture
W/O:
ECG
CPK-MB, troponin
CXR
Echocardiography
CBC
Upper endoscopy -
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. -
D/D:
Costochondritis
Pneumonia
MI
Pulmonary embolism
Pericarditis
Muscle strain
W/O:
ECG
CPK-MB, troponin
CXR
CBC -
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. -
D/D:
Pulmonary embolism
Pneumonia
Costochondritis
MI
CHF
Aortic dissection
W/O:
ECG
CXR
ABG
CPK-MB, troponin
CBC, electrolytes
CT—chest with IV contrast
Doppler U/S—legs
D-dimer -
55 yo M presents with sudden onset of
severe chest pain that radiates to the
back. He has a history of uncontrolled
hypertension. -
D/D:
Aortic dissection
MI
Pericarditis
Esophageal rupture
Esophageal spasm
GERD
Pancreatitis
W/O:
ECG, CPK-MB, troponin
CXR
CBC, amylase, lipase
Transesophageal
echocardiography (TEE),
MRI/MRA—aorta
Aortic angiography
Upper endoscopy