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Differential diagnosis of chest pain
Quiz by Nada Hassan Ahmed Abdelrahman
Tag the questions with any skills you have. Your dashboard will track each student's mastery of each skill.
A 32-year-old woman presents with a 2-day history of shortness of breath and right-sided chest pain. There is no history of fever or cough. She has a past medical history of a left lower limb deep vein thrombosis (DVT) 3 years ago. She is a current smoker with a 15-pack-year history. She is afebrile. Her heart rate is 121bpm and regular with a blood pressure of 134/88mmHg. On auscultation, her chest is clear with saturations of 93% on air and there are normal heart sounds. Her calves are soft and non-tender, and there is no pitting oedema.
Investigations:
Hb 160 g/L Male: (135-180)Female: (115 - 160)
Haematocrit 0.54 L/L Male: (0.4-0.54) Female: (0.37-0.47)
Platelets 223 * 109/L (150 - 400)
WBC 9.1 * 109/L (4.0 - 11.0)
Troponin 26 ng/mL (0-14)
CRP 10 mg/L (< 5)
ECG: sinus tachycardia and T wave inversion in V1-V4.
What is the most likely underlying diagnosis?
A 24-year-old man presents with left-sided chest pain. This came on suddenly while watching television. He denies shortness of breath and has no other symptoms. He has no past medical history, nor does he take any regular medications. He smokes 10 cigarettes per day.
On examination, he appears well in himself. There is no tenderness. On auscultation, left-sided breath sounds are reduced. Percussion is hyper-resonant on the left side. Observations are all within normal ranges. A chest X-ray demonstrates a 1.5cm rim of air between the left lung margin and the chest wall.
Which of the following is the most appropriate management of this patient?
A 35-year-old married woman presents with sudden onset of right-sided chest pain and shortness of breath associated with the start of her menstrual period. This occurred during her last menstrual period but she took no notice of it given that it resolved eventually. On this occasion, she reports the pain to be more severe which some radiation to her shoulder.
What is the likely cause of the patient's symptoms?
A 30-year-old man presents with several days of progressive chest pain, pleuritic in nature and worse on lying down. He achieves some relief from the pain by sitting forward.
On examination, a pericardial rub is noted when leaning forward. Given the most likely diagnosis, which of the following electrocardiogram (ECG) findings is most specific?
A 57-year-old man presents with sudden-onset, tearing chest pain. He has a history of Marfan syndrome and hypertension. On examination, he is visibly shocked and observations are as follows: BP: 78/65 mmHg, HR: 161 beats/minute
Respiratory rate of 42 breaths/minute
Oxygen saturation of 95% on 8L/minute oxygen flow
What is the most appropriate diagnostic investigation?
A 58-year-old diabetic man presents with a three-month history of exertional chest pain that relieves upon rest. A previous ECG was normal but he has had no further investigation for his pain.
What is the most appropriate imaging for this man?
A 27-year-old lady presents with worsening shortness of breath, haemoptysis and pleuritic chest pain. A CTPA confirms the presence of a pulmonary embolism (PE) and she is commenced on apixaban. Both her mother and older brother have a history of venous thromboembolism.
Which of the following conditions is the most likely underlying cause?
A 78-year-old man experienced severe central chest pain, while in the surgical ward three days post-op a colectomy. An ECG performed shows ST elevation in the anterior leads. Aspirin and oxygen have been given.
What is the most appropriate treatment?
IV diamorphine + double his prednisolone dose7%IV diamorphine + 6%1%80%
A 72-year-old man presents with left-sided tearing chest pain. His vital include heart rate: 101 beats/min, BP: 182/97 mmHg, respiratory rate: 21/minute. On clinical examination was normal except a diastolic murmur audible at the lower left sternal edge in end-expiration. CT angiography of the chest is organized, which demonstrates an intimal flap proximal to the brachiocephalic vessels.
Given the diagnosis, what is the appropriate management?
A 64-year-old man presents with a 1-hour history of central crushing chest pain radiating to the jaw. He has a background of hypertension, type 2 diabetes mellitus and hypercholesterolaemia. His vital include BP - 84/63 mmHg, HR - 63 beats/min , temp - 37.4ºC, Oxy sat 89% on room air, RR - 26 breaths/min.
Physical examination reveals heart sounds I + II, with no additional heart sounds, and clear lung fields bilaterally. JVP: 8cm above the sternal angle and appears obviously distended.
ECG: ST elevation in leads II, III and aVF.
Echocardiography: predominantly right ventricular systolic dysfunction with right ventricular free wall dyskinesia.
Which one of these common interventions is likely to cause a rapid deterioration in this particular patient?
A 65-year-old diabetic man presents with chest pain, nausea and feeling lethargic. He is known to have chronic kidney disease stage 4 secondary to diabetic nephropathy. His renal function is deteriorating. An ECG taken on admission shows widespread ST elevation.
An echocardiogram shows a small effusion. What is the most appropriate next step in management?
A 59-year-old female is admitted to the Emergency Department with a 30-minute history of central chest pain radiating to her left arm. An ECG shows ST elevation in leads II, III, aVF. Which coronary artery is most likely to be affected?
A 26-year-old man presents with a 1-week history of left-sided chest pain. The pain is worse when he takes deep breaths. Over the past 6 weeks, he had been training daily for an upcoming hockey tournament. He is vitally stable. Physical examination shows tenderness to palpation of the left chest. An x-ray of the chest is shown. Which of the following is the most appropriate initial pharmacotherapy?
A 19-year-old woman presents with a 1-week history of severe pharyngitis and progressive neck swelling and a 1-day history of chest pain and shortness of breath. On examination, she has bilateral cervical lymphadenopathy and tonsillitis. She has a mild fever, heart rate 42 bpm. She has no clubbing or peripheral cyanosis. There are no audible murmurs.ECG shows a complete heart block with a ventricular escape rhythm at a rate of 40 bpm. CRP and troponin are elevated.What is the most likely underlying pathogen?
A 28-year-old man who is immunosuppressed secondary to HIV infection is admitted to hospital with dyspnoea and a dry cough. His chest x-ray shows bilateral interstitial pulmonary infiltrates and he is started on co-trimoxazole empirically. The following morning he complains of a sudden worsening of his dyspnoea associated with left-sided chest pain. Which complication is most likely to have developed?
A 26-year-old woman presents with sudden onset, pleuritic chest pain, worse on inspiration. She has some associated shortness of breath. She has no significant past medical history, nor family history. On examination, she appears dyspnoeic and a D-dimer test is positive. A subsequent CT pulmonary angiogram confirms a diagnosis of pulmonary embolism. There is no clear cause that could have provoked this. Accordingly, she is commenced on anticoagulation. For how long should this treatment continue?
A 55-year-old man with hypertension and hyperlipidemia presents with crushing chest pain that started an hour ago while walking uphill. The pain radiates down his left arm and rates it as a 7 on a 10-point scale. His pulse is 115/minute, respirations are 24/min, and blood pressure is 112/68 mm Hg. Cardiac examination shows no murmurs. A 12-lead ECG with right-sided leads is obtained. Which of the following medications, if administered, is most likely to cause serious complications in this patient?
A 50-year-old man diabetic and hypertensive presents with central constricting chest pain. Walking up the stairs triggers the pain. The pain goes away with resting. No other cardiac symptoms. He suffers from hypertension and diabetes. He takes verapamil for migraine prophylaxis. His other medications include GTN spray, aspirin, atorvastatin, Ramipril and metformin. On examination, his rhythm seems to be irregular. There is no murmur on auscultation of the heart. He is asking for a medication that would be helpful to prevent chest pain from occurring. What is the most appropriate treatment to prevent the occurrence of this pain?
A 67-year-old diabetic and hypertensive woman present with sudden onset of chest heaviness and shortness of breath for 4 hours. Her temperature is 36.7ºC, pulse is 110/min, respirations are 20/min, and blood pressure is 82/45 mm Hg. ECG shows normal sinus rhythm, with ST-segment elevation in leads II, III, aVF, as well as V1 and V2. Troponins are pending, and the cardiac catheterization service has been alerted. Which of the following is the most appropriate next step in management?
A 60-year-old diabetic and hypertensive man present with crushing substernal chest pain for the past 45 minutes. He received 325 mg of aspirin en route. Nitroglycerin does not relieve his pain. His temperature is 36.8°C, his pulse is 99/min, respirations are 18/min, and his blood pressure is 192/88 mm Hg. He appears diaphoretic. ECG shows ST-segment elevation in leads V1, V2, and V3. Which of the following is the most appropriate next step in management? Elimination toolABCDRepeat ECGE
A 71-year-old woman presents with STEMI . Which of the following biochemical measures would most likely be elevated and remain elevated for a week after this acute event?
A 55-year-old man presents with severe central chest pain for 2 hours. His temperature is 36.8°C, his pulse is 97/min, respirations are 18/min, and blood pressure is 163/91 mm Hg. Cardiovascular examination is normal. An ECG is obtained and it shows ST-elevations in leads V1-V6, as well as reciprocal changes in leads III and aVF. Which of the following complications is most likely to occur, and result in death during this admission?
A 65-year-old diabetic man presents with severe central chest pain for two hours. He says the pain began while he was sitting at the breakfast table, is heavy in nature, and radiates to his jaw. His temperature is 36.8°C (98°F), pulse is 97/min, respirations are 18/min, and blood pressure is 163/91 mm Hg. Cardiovascular examination shows no abnormalities. ECG shows sinus rhythm at 97/min without ST-segment or other changes. Cardiac biomarkers taken six hours after admission are not elevated. Which of the following is the most likely cause of his symptoms?
A 66-year-old diabetic man presents with left-sided chest pain that began at rest and lasted for 15 minutes before resolving. He says a similar episode occurred at rest yesterday. His temperature is 36.8°C , pulse is 87/min, respirations are 18/min, and blood pressure is 117/78 mm Hg. The cardiopulmonary examination is normal. ECG shows ST-depression in leads V2, V3, and V4. Laboratory investigations show elevated CK-MB and serum troponin I level. Chest X-ray is normal. Which of the following is the most likely diagnosis?
A 73-year-old male presents with nausea and retrosternal chest pain for 2 hours. His medical history includes type II diabetes mellitus, dyslipidemia, and hypertension. His temperature is 36.5°C, his pulse is 78/min, respirations are 17/min, and his blood pressure is 120/78 mm Hg.
Examination shows a man who appears pale and diaphoretic. The cardiopulmonary examination is normal. An ECG is obtained. Which of the following is the most likely diagnosis?
A 67-year-old hypertensive and ex-smoker present chest pain when going uphill. The pain does not radiate and lasted 5 minutes, improving on rest. He rates the pain as a 4 on a 10-point scale. ECG shows Q-waves and T-wave inversion in leads II, III, and aVF. No prior ECGs are available for comparison. Which of the following is the most appropriate next step in management?
