Welcome to MedGuide takes on chest pain. This is a very important differential to gain good understanding of in medical school – timely, critical and common its an exam, and ED, favourite. As such, this will be split into a few parts so that you can have as much practice into the clinical reasoning as possible. Good luck!
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Chest Pain 1
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Stem 1 of 5
A 72YOM patient presents with heaviness in the chest, at rest, for 2 hours. He feels sick, short of break and weak in all extremities. His history is notable for smoking 30 cigarettes daily for 12 years and controlled hyperlipidaemia and secondary hypertension. For his hypertension, he was told to lose weight and given a CPAP machine from the NHS.
Calculate the patient’s pack years
Question 1 Explanation:
Pack year’s are really easy to calculate. If X is the number of cigarettes per day, the formula is as follows: (X/20) * years smoked. So in this case the formula would be (30/20)*12=answer in pack/years.
Stem 2 of 5Which is the most likely cause of his ORDINARILY elevated systolic blood pressure?
Coarctation of the aorta
Obstructive sleep apnoea
Renal artery stenosis
Question 2 Explanation:
Due to a history of needing to lose weight, and being placed on a CPAP machine, this points to a history of obstructive sleep apnoea. Common secondary causes of hypertension are important to remember, one mnemonic I came up with is CAPTOR (coarctation, Conn’s, Cushing’s, acromegaly, pregnancy, thyroid, OSA, obesity, renal artery stenosis, renal failure).
Stem 3 of 5Which would be the least-expected examination finding in this patient?
A normal examination
Bilateral basal rales
Question 3 Explanation:
The exam finding in ACS is ordinarily normal. However, nausea can result in vomiting, heart failure can result in pulmonary congestion causing basal rales, a holo/pansystolic murmur can be a result of mitral regurgitation from papillary muscle rupture. A mid-diastolic murmur is more readily associated with mitral stenosis which is the least likely finding specifically in this patient.
Stem 4 of 5The patient shows contiguous lead ST elevation in V3, V4. Which coronary artery is most likely implicated?
Left anterior descending
Left circumflex artery
Left marginal artery
Posterior interventricular artery
Right marginal artery
Question 4 Explanation:
This patient is having a STEMI in the anterior limb leads. This territory of the heart is supplied by the left anterior descending artery. Make sure you can correlate lead territories to arterial territories - this is a common exam question.
Stem 5 of 5Based on the most likely diagnosis, which of the following investigations would be appropriate to order first line? Select all that may be appropriate options.
B-type natriuretic peptide
Question 5 Explanation:
In the STEMI patient, the first line investigations are always ECG at the bedside, cardiac bioenzymes in the bloods and CXR for imaging. All other investigations are secondary if ACS is the lead differential.
Stem 1 of 4
A 59 year old patient presents to his GP lucidly, with acute shortness of breath, productive cough and pain accentuated in inhalation. His resp rate is raised and he is pyrexic, but other vitals are within normal limits.
A CXR shows pulmonary infiltrates and pleural effusion unilaterally. What is the best matched differential?
Acute coronary syndrome
Community acquired pneumonia
Hospital acquired pneumonia
Small-cell lung cancer
Question 6 Explanation:
Pleuritic chest pain with lower respiratory signs and fever suggests pneumonia. The other potential diagnosis, which would form a differential basis due more to severity than likelihood, is pulmonary embolism ± ACS.
Stem 2 of 4The patient has no known medical history or concerning exposures. Which is the most likely causative organism?
Question 7 Explanation:
Up to 80% of all community-acquired pneumonia in the UK is said to be caused by S. pneumoniae.
Stem 3 of 4Using a NICE-approved calculation, how would you arrange care for this patient?
Call ambulance for <1 hour transfer to hospital
Call ambulance for 3 hour transfer to hospital
Reassure with no treatment needed
Treat in the community with PO antibiotics
Urgent referral for outpatient chest X-ray
Question 8 Explanation:
Given the patient receiving 1 on CRB65 (the modified primary care scale of CURB65), you would consider transfer, non-urgently, to hospital. A score of 0 would make you more comfortable to care in the community with oral antibiotics. This does not call for a blue-lights, <1hr ambulance which is the suggestion of near-immediate threat to life.
Stem 4 of 4What is the first line medication for this patient?
Coamoxiclav + clarithromycin
Question 9 Explanation:
NICE Guidelines state: “first choice oral antibiotics if moderate severity guided by microbiological results when available include amoxicillin with clarithromycin or erythromycin (latter in pregnancy)”. Note that NICE states to only add a second line medication to amoxicillin if an atypical organism is expected which it is not in this case. It is worth noting that CRB65 is not validated for COVID19 patients, and during the 2020-21 pandemic, NG20 changed the first line oral medication to doxycycline for low-intensity community-acquired pneumonia. This was to cover the wider-spectrum of superimposed bacterial infections likely alongside COVID pneumonitis.
Stem 1 of 2
A 22YOF presents to the ED short of breath acutely with pleuritic, focal chest pain. She has no notable history, medical or drug history and has never been to a Doctor before.
Given her demography, and history, a CXR is performed and is clear. What is the best-matched differential?
Question 10 Explanation:
The clear chest X-ray and low scoring of a Well’s criteria would not suggest a PE. Given her demography, ischaemic heart disease without any PMHx would be extremely unlikely.
Stem 2 of 2What would be the next best step?
Naproxen with omeprazole
Question 11 Explanation:
In a young patient with no gastrointestinal history, cover with a proton pump inhibitor should serve no benefit. A second line therapy for inflammatory costochondritis could be intraarticular corticosteroid injection if refractory.
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