| Chest Pain | ||||
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Coronary Angioplasty |
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| Useful ECG Videos | ||||
Chest Pain – Revision Questions
1. A 55-year-old man presents with sudden onset, severe chest pain that radiates to his back and is described as tearing in nature. What is the most likely diagnosis?
Options:
- A) Myocardial infarction
- B) Pulmonary embolism
- C) Aortic dissection
- D) Pericarditis
- E) Pneumothorax
Show Answer
Answer: C) Aortic dissection
Justification: The presentation of sudden, severe, tearing chest pain radiating to the back is highly suggestive of an aortic dissection, especially in older patients or those with hypertension.
2. A 65-year-old female presents with central chest pain that is worse on inspiration and lying flat, and relieved by sitting forward. What is the most likely diagnosis?
Options:
- A) Myocardial infarction
- B) Gastroesophageal reflux disease
- C) Pericarditis
- D) Angina
- E) Costochondritis
Show Answer
Answer: C) Pericarditis
Justification: Pericarditis typically presents with sharp chest pain that worsens with inspiration and lying flat and is relieved by sitting forward, often associated with a pericardial friction rub on auscultation.
3. A 70-year-old male with a history of hypertension presents with chest pain, dyspnea, and a feeling of impending doom. What is the most appropriate initial test?
Options:
- A) Chest X-ray
- B) ECG
- C) CT Pulmonary Angiography
- D) Troponin level
- E) D-dimer
Show Answer
Answer: B) ECG
Justification: An ECG is the most appropriate initial test in a patient presenting with chest pain, dyspnea, and concerning symptoms such as a feeling of impending doom, to assess for myocardial ischemia or infarction.
4. A 35-year-old female with a history of anxiety presents with chest pain, palpitations, and dizziness. What is the most likely diagnosis?
Options:
- A) Pulmonary embolism
- B) Panic attack
- C) Myocardial infarction
- D) Costochondritis
- E) Pneumothorax
Show Answer
Answer: B) Panic attack
Justification: Panic attacks often present with chest pain, palpitations, dizziness, and a sense of impending doom, especially in patients with a history of anxiety.
5. A 60-year-old male smoker presents with acute onset pleuritic chest pain and shortness of breath. What is the most likely diagnosis?
Options:
- A) Pneumonia
- B) Myocardial infarction
- C) Pneumothorax
- D) Gastroesophageal reflux disease
- E) Angina
Show Answer
Answer: C) Pneumothorax
Justification: Sudden onset pleuritic chest pain and shortness of breath in a smoker, particularly with no other obvious cause, strongly suggests a pneumothorax.
6. A 45-year-old female with a history of hypertension presents with chest pain and shortness of breath after a long-haul flight. What is the most likely diagnosis?
Options:
- A) Myocardial infarction
- B) Pulmonary embolism
- C) Aortic dissection
- D) Angina
- E) Costochondritis
Show Answer
Answer: B) Pulmonary embolism
Justification: Pulmonary embolism is highly likely in a patient with recent immobility (e.g., long-haul flight), presenting with chest pain and dyspnea.
7. A 50-year-old male with diabetes presents with a dull, central chest pain that radiates to the left arm and is associated with sweating. What is the most likely diagnosis?
Options:
- A) Gastroesophageal reflux disease
- B) Myocardial infarction
- C) Pulmonary embolism
- D) Pericarditis
- E) Pneumonia
Show Answer
Answer: B) Myocardial infarction
Justification: Central chest pain radiating to the left arm, especially with associated sweating, strongly suggests myocardial infarction, particularly in patients with cardiovascular risk factors such as diabetes.
8. A 28-year-old male presents with sharp chest pain that worsens with movement and deep breaths. There is tenderness to palpation over the costochondral junction. What is the most likely diagnosis?
Options:
- A) Pulmonary embolism
- B) Myocardial infarction
- C) Costochondritis
- D) Pneumothorax
- E) Pericarditis
Show Answer
Answer: C) Costochondritis
Justification: Costochondritis presents with sharp, localized chest pain that worsens with movement or palpation over the costochondral junctions, often related to physical activity or trauma.
9. A 67-year-old male with a history of heavy smoking presents with chronic cough, weight loss, and chest pain. What is the most likely diagnosis?
Options:
- A) Tuberculosis
- B) Lung cancer
- C) Pulmonary embolism
- D) COPD exacerbation
- E) Pneumonia
Show Answer
Answer: B) Lung cancer
Justification: Chronic cough, weight loss, and chest pain in a heavy smoker are highly suggestive of lung cancer.
10. A 55-year-old female presents with retrosternal burning pain that occurs after eating and is relieved by antacids. What is the most likely diagnosis?
Options:
- A) Myocardial infarction
- B) Angina
- C) Gastroesophageal reflux disease
- D) Pericarditis
- E) Peptic ulcer disease
Show Answer
Answer: C) Gastroesophageal reflux disease
Justification: Retrosternal burning pain that occurs after eating and is relieved by antacids is characteristic of gastroesophageal reflux disease (GERD).
OSCE Station: Chest Pain Assessment
Instructions for Candidate
You have 1 minute of reading time and 7 minutes for this OSCE station. Your task is to assess a patient presenting with chest pain. Use the checklist provided to ensure you cover all key areas.
Scenario
A 58-year-old male presents to the emergency department with chest pain. The pain started one hour ago while he was watching TV. It is described as a heavy, crushing sensation that radiates to the left arm and jaw. The patient has a history of hypertension, hyperlipidemia, and smoking.
Patient Background Information for Role-Player
- Name: Mr. John Smith
- Age: 58
- Presenting complaint: Chest pain for 1 hour
- History: Smoker, hypertension, high cholesterol
- Pain description: Heavy, crushing pain, radiating to the left arm and jaw, 8/10 in severity.
- Associated symptoms: Sweating, nausea
- No known allergies
- Medications: Amlodipine, Atorvastatin
Checklist for Marksheet
Instructions: Check the boxes as you complete each task. Total your score at the end.
1. Introduction and Initial Assessment (3 marks)
- Introduces self and confirms patient details (1 mark)
- Asks about the main complaint clearly (1 mark)
- Assesses for immediate life-threatening symptoms (e.g., severity, onset, radiation) (1 mark)
2. History of Presenting Complaint (5 marks)
- Asks about onset, character, location, duration, and radiation of the pain (1 mark)
- Inquires about associated symptoms (e.g., shortness of breath, nausea, sweating, palpitations) (1 mark)
- Asks about aggravating and relieving factors (1 mark)
- Asks about previous similar episodes (1 mark)
- Inquires about any recent exertion, trauma, or stress (1 mark)
3. Past Medical History (3 marks)
- Asks about relevant medical history (hypertension, hyperlipidemia, heart disease) (1 mark)
- Asks about medication history (1 mark)
- Asks about known allergies (1 mark)
4. Social History (2 marks)
- Asks about smoking, alcohol use, and drug use (1 mark)
- Inquires about lifestyle and exercise habits (1 mark)
5. Family History (1 mark)
- Asks about family history of cardiovascular disease (1 mark)
6. Physical Examination (5 marks)
- Checks vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) (1 mark)
- Examines the cardiovascular system (inspects chest, palpates for heaves and thrills, auscultates heart sounds) (1 mark)
- Examines the respiratory system (inspects, palpates, percusses, and auscultates the lungs) (1 mark)
- Checks peripheral pulses and looks for signs of poor perfusion (1 mark)
- Examines for any signs of heart failure (e.g., peripheral edema, raised JVP) (1 mark)
7. Investigations and Management Plan (4 marks)
- Suggests appropriate initial investigations (ECG, cardiac enzymes, chest X-ray) (1 mark)
- Discusses differential diagnoses (e.g., myocardial infarction, angina, pulmonary embolism, aortic dissection) (1 mark)
- Outlines initial management plan (oxygen, aspirin, nitrates, morphine if indicated) (1 mark)
- Advises about need for cardiology referral and possible further intervention (1 mark)
8. Communication and Closing (2 marks)
- Communicates findings and plan clearly to the patient (1 mark)
- Offers reassurance and checks for patient understanding (1 mark)
Total: 25 marks
Pass Mark: 15/25
Examiner’s Notes:
- Observe the student’s communication skills, including empathy and clarity.
- Ensure the student addresses red flags for serious conditions like myocardial infarction.
- Evaluate the logical flow of the history-taking and examination.
- Consider how well the student formulates a differential diagnosis and management plan.
Chest Pain – Revision Questions
1. A 55-year-old man presents with sudden onset, severe chest pain that radiates to his back and is described as tearing in nature. What is the most likely diagnosis?
Options:
- A) Myocardial infarction
- B) Pulmonary embolism
- C) Aortic dissection
- D) Pericarditis
- E) Pneumothorax
Show Answer
Answer: C) Aortic dissection
Justification: The presentation of sudden, severe, tearing chest pain radiating to the back is highly suggestive of an aortic dissection, especially in older patients or those with hypertension.
2. A 65-year-old female presents with central chest pain that is worse on inspiration and lying flat, and relieved by sitting forward. What is the most likely diagnosis?
Options:
- A) Myocardial infarction
- B) Gastroesophageal reflux disease
- C) Pericarditis
- D) Angina
- E) Costochondritis
Show Answer
Answer: C) Pericarditis
Justification: Pericarditis typically presents with sharp chest pain that worsens with inspiration and lying flat and is relieved by sitting forward, often associated with a pericardial friction rub on auscultation.
3. A 70-year-old male with a history of hypertension presents with chest pain, dyspnea, and a feeling of impending doom. What is the most appropriate initial test?
Options:
- A) Chest X-ray
- B) ECG
- C) CT Pulmonary Angiography
- D) Troponin level
- E) D-dimer
Show Answer
Answer: B) ECG
Justification: An ECG is the most appropriate initial test in a patient presenting with chest pain, dyspnea, and concerning symptoms such as a feeling of impending doom, to assess for myocardial ischemia or infarction.
4. A 35-year-old female with a history of anxiety presents with chest pain, palpitations, and dizziness. What is the most likely diagnosis?
Options:
- A) Pulmonary embolism
- B) Panic attack
- C) Myocardial infarction
- D) Costochondritis
- E) Pneumothorax
Show Answer
Answer: B) Panic attack
Justification: Panic attacks often present with chest pain, palpitations, dizziness, and a sense of impending doom, especially in patients with a history of anxiety.
5. A 60-year-old male smoker presents with acute onset pleuritic chest pain and shortness of breath. What is the most likely diagnosis?
Options:
- A) Pneumonia
- B) Myocardial infarction
- C) Pneumothorax
- D) Gastroesophageal reflux disease
- E) Angina
Show Answer
Answer: C) Pneumothorax
Justification: Sudden onset pleuritic chest pain and shortness of breath in a smoker, particularly with no other obvious cause, strongly suggests a pneumothorax.
6. A 45-year-old female with a history of hypertension presents with chest pain and shortness of breath after a long-haul flight. What is the most likely diagnosis?
Options:
- A) Myocardial infarction
- B) Pulmonary embolism
- C) Aortic dissection
- D) Angina
- E) Costochondritis
Show Answer
Answer: B) Pulmonary embolism
Justification: Pulmonary embolism is highly likely in a patient with recent immobility (e.g., long-haul flight), presenting with chest pain and dyspnea.
7. A 50-year-old male with diabetes presents with a dull, central chest pain that radiates to the left arm and is associated with sweating. What is the most likely diagnosis?
Options:
- A) Gastroesophageal reflux disease
- B) Myocardial infarction
- C) Pulmonary embolism
- D) Pericarditis
- E) Pneumonia
Show Answer
Answer: B) Myocardial infarction
Justification: Central chest pain radiating to the left arm, especially with associated sweating, strongly suggests myocardial infarction, particularly in patients with cardiovascular risk factors such as diabetes.
8. A 28-year-old male presents with sharp chest pain that worsens with movement and deep breaths. There is tenderness to palpation over the costochondral junction. What is the most likely diagnosis?
Options:
- A) Pulmonary embolism
- B) Myocardial infarction
- C) Costochondritis
- D) Pneumothorax
- E) Pericarditis
Show Answer
Answer: C) Costochondritis
Justification: Costochondritis presents with sharp, localized chest pain that worsens with movement or palpation over the costochondral junctions, often related to physical activity or trauma.
9. A 67-year-old male with a history of heavy smoking presents with chronic cough, weight loss, and chest pain. What is the most likely diagnosis?
Options:
- A) Tuberculosis
- B) Lung cancer
- C) Pulmonary embolism
- D) COPD exacerbation
- E) Pneumonia
Show Answer
Answer: B) Lung cancer
Justification: Chronic cough, weight loss, and chest pain in a heavy smoker are highly suggestive of lung cancer.
10. A 55-year-old female presents with retrosternal burning pain that occurs after eating and is relieved by antacids. What is the most likely diagnosis?
Options:
- A) Myocardial infarction
- B) Angina
- C) Gastroesophageal reflux disease
- D) Pericarditis
- E) Peptic ulcer disease
Show Answer
Answer: C) Gastroesophageal reflux disease
Justification: Retrosternal burning pain that occurs after eating and is relieved by antacids is characteristic of gastroesophageal reflux disease (GERD).
OSCE Station: Chest Pain Assessment
Instructions for Candidate
You have 1 minute of reading time and 7 minutes for this OSCE station. Your task is to assess a patient presenting with chest pain. Use the checklist provided to ensure you cover all key areas.
Scenario
A 58-year-old male presents to the emergency department with chest pain. The pain started one hour ago while he was watching TV. It is described as a heavy, crushing sensation that radiates to the left arm and jaw. The patient has a history of hypertension, hyperlipidemia, and smoking.
Patient Background Information for Role-Player
- Name: Mr. John Smith
- Age: 58
- Presenting complaint: Chest pain for 1 hour
- History: Smoker, hypertension, high cholesterol
- Pain description: Heavy, crushing pain, radiating to the left arm and jaw, 8/10 in severity.
- Associated symptoms: Sweating, nausea
- No known allergies
- Medications: Amlodipine, Atorvastatin
Checklist for Marksheet
Instructions: Check the boxes as you complete each task. Total your score at the end.
1. Introduction and Initial Assessment (3 marks)
- Introduces self and confirms patient details (1 mark)
- Asks about the main complaint clearly (1 mark)
- Assesses for immediate life-threatening symptoms (e.g., severity, onset, radiation) (1 mark)
2. History of Presenting Complaint (5 marks)
- Asks about onset, character, location, duration, and radiation of the pain (1 mark)
- Inquires about associated symptoms (e.g., shortness of breath, nausea, sweating, palpitations) (1 mark)
- Asks about aggravating and relieving factors (1 mark)
- Asks about previous similar episodes (1 mark)
- Inquires about any recent exertion, trauma, or stress (1 mark)
3. Past Medical History (3 marks)
- Asks about relevant medical history (hypertension, hyperlipidemia, heart disease) (1 mark)
- Asks about medication history (1 mark)
- Asks about known allergies (1 mark)
4. Social History (2 marks)
- Asks about smoking, alcohol use, and drug use (1 mark)
- Inquires about lifestyle and exercise habits (1 mark)
5. Family History (1 mark)
- Asks about family history of cardiovascular disease (1 mark)
6. Physical Examination (5 marks)
- Checks vital signs (heart rate, blood pressure, respiratory rate, oxygen saturation) (1 mark)
- Examines the cardiovascular system (inspects chest, palpates for heaves and thrills, auscultates heart sounds) (1 mark)
- Examines the respiratory system (inspects, palpates, percusses, and auscultates the lungs) (1 mark)
- Checks peripheral pulses and looks for signs of poor perfusion (1 mark)
- Examines for any signs of heart failure (e.g., peripheral edema, raised JVP) (1 mark)
7. Investigations and Management Plan (4 marks)
- Suggests appropriate initial investigations (ECG, cardiac enzymes, chest X-ray) (1 mark)
- Discusses differential diagnoses (e.g., myocardial infarction, angina, pulmonary embolism, aortic dissection) (1 mark)
- Outlines initial management plan (oxygen, aspirin, nitrates, morphine if indicated) (1 mark)
- Advises about need for cardiology referral and possible further intervention (1 mark)
8. Communication and Closing (2 marks)
- Communicates findings and plan clearly to the patient (1 mark)
- Offers reassurance and checks for patient understanding (1 mark)
Total: 25 marks
Pass Mark: 15/25
Examiner’s Notes:
- Observe the student’s communication skills, including empathy and clarity.
- Ensure the student addresses red flags for serious conditions like myocardial infarction.
- Evaluate the logical flow of the history-taking and examination.
- Consider how well the student formulates a differential diagnosis and management plan.
