Cardiology 1 Evaluation of Chest Pain

Lecture Outline
I.

Cardiac Causes of Chest Pain

A. Stable angina
B. Acute coronary syndrome
1. Unstable angina
2. Myocardial infarction
C. Pericarditis
D. Myocarditis
E. Valvular heart disease
F. Aortic dissection
II. Non-Cardiac Causes of Chest Pain
A. Musculoskeletal
B. Gastrointestinal
C. Pulmonary
D. Neurological and Psychiatric

Cardiac Chest Pain

1. What is the classic description of anginal chest pain?

2. What EKG changes are classically seen with pericarditis?

3. What is the classic description of the pain of aortic dissection?

Musculoskeletal Chest Pain

4. What is the name for pain at the attachment of the ribs to the sternum at the costosternal junction?

Gastrointestinal Chest Pain

5. What features of chest pain might suggest esophageal pain from GERD or reflux esophagitis?

6. What is another name for esophageal rupture?

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7. In peptic ulcer disease, how does the timing of pain classically help differentiate between
gastric and duodenal ulcers?

8. Where might chest pain from biliary disease radiate?

Quick Review
9. What is the classic chest x-ray finding associated with a thoracic aortic dissection?

10. A 45-year-old male presents to the ER with acute chest pain that is relieved with sublingual nitroglycerin. The
patient begins to have pain at rest, so he goes on to have a cardiac catheterization for what is believed to be
worsening coronary artery disease. Cardiac catheterization showed minimal atherosclerotic disease. What
are some instances where non-ischemic chest pain is relieved with nitroglycerin?

11. How does Boerhaaves syndrome differ from a Mallory-Weiss tear?

12. A patient describes her chest pain as sharp pain that is worsened by deep inspiration or coughing. The pain is
worse when she is supine, and is better when sitting up and leaning forward. What is a likely cause of her
chest pain?

13. What are some common conditions associated with pericarditis?

Pulmonary Chest Pain

14. How is the pain of pleuritis described?

15. What two pulmonary causes of chest pain are considered medical emergencies?

16. What signs and symptoms might suggest pneumonia as a cause of chest pain?

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Neurologic and Psychiatric Chest Pain

17. What features of chest pain would suggest herpes zoster?

18. In addition to chest pain, what symptoms can accompany panic attacks?

19. What items on your chest pain differential can be evaluated with a chest x-ray?

20. If you have an obese 45-year-old woman with atypical chest pain and normal EKG, but the alkaline
phosphatase and bilirubin are slightly elevated, what disease might to you look for?

21. If you have a patient who has been immobilized due to recent surgery who now presents with acute shortness
of breath and chest pain, what disease might you look for?

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End of Session Quiz

1. What five causes of chest pain are considered medical emergencies?
Heart:
Aorta:
Esophagus :
Lungs :

2. What is the classic description of anginal chest pain?

3. Why is it important to palpate the chest when assessing a patient experiencing chest pain?

4. What is the classic description of the rash seen in herpes zoster?

5. What is the most likely cause of chest pain in each of the following scenarios?
Patient is able to point to localize the chest pain
using one finger
Chest wall tenderness on palpation
Rapid onset sharp chest pain that radiates to the
back
Rapid onset sharp pain in a 20-year-old, associated
with dyspnea
ST segment elevation only during brief episodes of
chest pain
Occurs after heavy meals and improved by
antacids
Sharp pain lasting hours to days, somewhat
relieved by sitting forward
Pain made worse by deep breathing and/or
motion
Chest pain in a dermatomal distribution
Acute-onset dyspnea, tachycardia, and confusion
in a hospitalized patient
Pain began the day following an intensive new
exercise program

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6. A 32-year-old woman presents to the ER complaining of chest pain, which you strongly suspect to be
psychogenic in nature. What is the difference between factitious disorder and malingering?

7. What is the classic EKG finding seen in a patient pulmonary embolism? What is the most common EKG
finding?

8. What kind of patient would classically be prone to a spontaneous pneumothorax?

9. A 35-year-old man is brought to the ER following a motor vehicle collision. He is alert and cooperative, but
complains or left-sided chest pain and difficulty breathing. He has no breath sounds on the left, and the left
chest is hyperresonant to percussion, and tension pneumothorax is suspected. What is the next step in
management?

10. What are the 3 most important tests use to evaluate a patient with chest pain?

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