Key History
Location, quality, severity, radiation, duration, context (exertional, postprandial, positional, cocaine use, trauma); associated symptoms (sweating, nausea, dyspnea, palpitations, sense of doom, fever); exacerbating and alleviating factors (especially medications); 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).
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; lower extremity exam (inspection for signs of DVT).
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Presentation |
Differential |
Workup |
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■ 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. |
Myocardial infarction (MI) GERD Angina Costochondritis Aortic dissection Pericarditis Pulmonary embolism Pneumothorax |
ECG CPK-MB, troponin x 3 CXR CBC Electrolytes Echocardiography Cardiac catheterization D-dimer Helical CT |
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■ 20 yo African American F presents with acute onset of severe chest pain for a few hours. She has a history of sickle cell disease and multiple hospitalizations for pain and anemia management. |
Sickle cell disease—acute chest syndrome Pulmonary embolism Pneumonia MI Pneumothorax Aortic dissection |
CBC with reticulocyte count and peripheral smear LDH ABG D-dimer CXR CPK-MB, troponin ECG CTA—chest with IV contrast |
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■ 45 yo F presents with a retrosternal burning sensation that occurs after heavy meals and when lying down. Her symptoms are relieved by antacids. |
GERD Esophagitis Peptic ulcer disease Esophageal spasm MI Angina |
ECG Barium swallow Upper endoscopy Esophageal pH monitoring |
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CHEST PAIN (cont'd) |
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■ 55 yo M presents with retrosternal squeezing pain that lasts for 2 minutes and occurs with exercise. It is relieved by rest and is not related to food intake. |
Stable angina Esophageal spasm Esophagitis |
ECG CPK-MB, troponin CXR CBC Electrolytes Exercise stress test Upper endoscopy/pH monitor Cardiac catheterization |
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■ 34 yo F presents with retrosternal stabbing chest pain that improves when she leans forward and worsens with deep inspiration. She had a URI 1 week ago. |
Pericarditis Aortic dissection MI Costochondritis GERD Esophageal rupture |
ECG CPK-MB, troponin CXR Echocardiography CBC Upper endoscopy ESR |
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■ 33 yo F presents with stabbing chest pain that worsens with deep inspiration and is relieved by aspirin. She had a URI 1 week ago. Chest wall tenderness is noted. |
Costochondritis Pneumonia MI Pulmonary embolism Pericarditis Pleurisy Muscle strain |
ECG CPK-MB, troponin CXR CBC |
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■ 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. |
Pulmonary embolism Pneumonia Costochondritis MI CHF Aortic dissection |
D-dimer ECG CXR ABG CPK-MB, troponin CBC Electrolytes, BUN/Cr, glucose CTA—chest with IV contrast Doppler U/S—legs |
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CHEST PAIN (cant'd) |
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■ 55 yo M presents with sudden onset of severe chest pain that radiates to his back. He has a history of uncontrolled hypertension. |
Aortic dissection MI Pericarditis Esophageal rupture Esophageal spasm GERD Pancreatitis Fat embolism |
ECG CPK-MB, troponin CXR CBC Amylase, lipase CTA—chest with IV contrast Transesophageal echocardiography (TEE) MRI/MRA—aorta Aortic angiography Upper endoscopy |
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