First Aid for the USMLE Step 2 CS

Section 3. Minicases

Chest Pain

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).

 

Presentation

Differential

Workup

■ 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

■ 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

■ 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

CHEST PAIN (cont'd)

Presentation

Differential

Workup

 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

 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

 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

■ 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

CHEST PAIN (cant'd)

Presentation

Differential

Workup

■ 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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