Chest pain and Dyspnoea

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Approach for learning

1. Exam approach

2. Case approach

3. Topic / Knowledge approach

4. Guideline approach

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Course Objectives

1. To recognize the differential diagnosis of chest pain and dyspnoea in general

2. To recognize the life threatening differential diagnosis of chest pain and dyspnoea

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Outline for today presentation

1. Constructing differential diagnosis of chest pain and dyspnoea

2. Cases approach

3. Guideline approach

4. Assessment questions

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Outline for today presentation

1. Constructing differential diagnosis of chest pain and dyspnoea

2. Cases approach

3. Guideline approach

4. Assessment questions

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Chest pain and Dyspnoea / Breathlessness
• Chest pain without dyspnoea

• Dyspnoea without chest pain

• Chest pain with Dyspnoea

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Constructing a differential diagnosis of chest pain
(best remembered anatomically from skin to internal organs)

I. Skin – Herpes zoster

II. Breast – Fibroadenoma, Mastitis, Gynaecomastia
III. Musculoskeletal – Costochondritis, Tietz syndrome, Precordial catch syndrome, Pectoral muscle strain, rib fracture,
cervical or thoracic spondylosis (C4-T6), myositis
IV. Esophageal – Spasm, Rupture, GERD, Esophagitis, Neoplasm
V. Gastrointestinal – Peptic ulcer, Gall bladder disease, liver abscess, Subdiaphragmatic abscess, Pancreatitis
VI. Pulmonary
i. Pleural disease (Pleuritis, Pleural effusion, Pneumothorax, Neoplasm)
ii. Lung Parenchyma and vasculature (Pneumonia, Pulmonary embolism, Neoplasm)
VII. Cardiac – Acute coronary syndorome (ACS) (unstable angina, myocardial infarction), Pericarditis, Myocarditis, Stable
angina
VIII. Vascular – Acute aortic syndrome (AAS) (thoracic aortic dissection, intraluminal hematoma, aneurysm)
IX. Mediastinal structures – Lymphoma, Thymoma
X. Psychiatric
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Exclude life threatening causes first
The main life-threatening differential diagnoses to consider when taking a history from a sick patient presenting
with chest pain are
1. Myocardial infarction (ACS)
2. Pulmonary embolism
3. Thoracic aortic dissection
4. Tension pneumothorax
5. Esophageal rupture
– these all require immediate and appropriate treatment.

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Constructing a differential diagnosis of chest pain
(best remembered anatomically from skin to internal organs)

I. Skin – Herpes zoster

II. Breast – Fibroadenoma, Mastitis, Gynaecomastia
III. Musculoskeletal – Costochondritis, Tietz syndrome, Precordial catch syndrome, Pectoral muscle strain, rib fracture,
cervical or thoracic spondylosis (C4-T6), myositis
IV. Esophageal – Spasm, Rupture, GERD, Esophagitis, Neoplasm
V. Gastrointestinal – Peptic ulcer, Gall bladder disease, liver abscess, Subdiaphragmatic abscess, Pancreatitis
VI. Pulmonary
I. Pleural disease (Pleuritis, Pleural effusion, Pneumothorax, Neoplasm)
II. Lung Parenchyma and vasculature (Pneumonia, Pulmonary embolism, Neoplasm)
VII. Cardiac – Acute coronary syndorome (ACS) (unstable angina, myocardial infarction), Pericarditis, Myocarditis, Stable
angina
VIII. Vascular – Acute aortic syndrome (AAS) (thoracic aortic dissection, intraluminal hematoma, aneurysm)
IX. Mediastinal structures – Lymphoma, Thymoma
X. Psychiatric
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Constructing a differential diagnosis of dyspnoea
A. Lung
I. Airway - Suprathoracic airways (i.e. laryngeal edema), Intrathoracic airways (I.e. Asthma, COPD)
II. Alveoli (can fill with water, pus or blood) - Pulmonary edema (Heart failure, ARDS), Pneumonia, Pulmonary hemorrhage
III. Interstitial
i. Edema
ii. Inflammation - organic exposure (e.g. cotton), mineral exposures (e.g. asbestos), idiopathic disease (sarcoidosis, scleroderma)
iii. Infection (Pneumocystis)
iv. Malignancy (can occur all areas of lung)
IV. Pleural - Pneumothorax, Pleural effusion
V. Blood vessels - Pulmonary embolism, Pulmonary hypertension
B. Heart
I. Endocardium - VHD
II. Myocardium - HFrEF, HFpEF
III. Pericardium - tamponade, constrictive pericarditis
IV. Conduction system - Bradycardia (SSS), Heart block), Tachycardia (AF, SVT, VT)
V. Coronary artery - ischemia and infarction
C. Chest wall / Neuromuscular disease - Kyphoscoliosis, muscle weakness (myopathy, GBS), Obesity
D. Anemia
E. Metabolic disorders - acidosis (DKA), hyperthyroidism 11
Constructing a differential diagnosis of dyspnoea

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Exclude life threatening causes first
The main life-threatening differential diagnoses to consider when taking a history from a sick patient presenting
with dyspnoea are
1. ACS - Myocardial infarction
2. Arrhythmia
3. Airway obstruction, Anaphylaxis
4. Acute pulmonary edema
5. Tamponade
6. Pneumothorax
7. Pulmonary embolism
– these all require immediate and appropriate treatment.

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Constructing a differential diagnosis of dyspnoea
A. Lung
I. Airway - Suprathoracic airways (i.e. laryngeal edema), Intrathoracic airways (I.e. Asthma, COPD)
II. Alveoli (can fill with water, pus or blood) - Pulmonary edema (Heart failure, ARDS), Pneumonia, Pulmonary hemorrhage
III. Interstitial
i. Edema
ii. Inflammation - organic exposure (e.g. cotton), mineral exposures (e.g. asbestos), idiopathic disease (sarcoidosis, scleroderma)
iii. Infection (Pneumocystis)
iv. Malignancy (can occur all areas of lung)
IV. Pleural - Pneumothorax, Pleural effusion
V. Blood vessels - Pulmonary embolism, Pulmonary hypertension
B. Heart
I. Endocardium - VHD
II. Myocardium - HFrEF, HFpEF
III. Pericardium - tamponade, constrictive pericarditis
IV. Conduction system - Bradycardia (SSS), Heart block), Tachycardia (AF, SVT, VT)
V. Coronary artery - ischemia and infarction
C. Chest wall / Neuromuscular disease - Kyphoscoliosis, muscle weakness (myopathy, GBS), Obesity
D. Anemia
E. Metabolic disorders - acidosis (DKA), hyperthyroidism 14
Chest pain and Dyspnoea / Breathlessness

• Chest pain without dyspnoea - from skin to internal organs

• Dyspnoea without chest pain - Respiratory, Cardiac, non cardiorespiratory (e.g. chest

wall / neuromuscular disease, anemia, metabolic, ?psychogenic)

• Chest pain with Dyspnoea - Cardiac + Respiratory causes

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Differential diagnosis of dyspnoea associated with
chest pain

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Constructing a differential diagnosis of chest pain
+ Dyspnoea (best remembered anatomically from skin to internal organs)
I. Skin – Herpes zoster
II. Breast – Fibroadenoma, Mastitis, Gynaecomastia Complicated by pneumothorax
III. Musculoskeletal – Costochondritis, Tietz syndrome, Precordial catch syndrome, Pectoral muscle strain, rib fracture,
cervical or thoracic spondylosis (C4-T6), myositis
IV. Esophageal – Spasm, Rupture, GERD, Esophagitis, Neoplasm
Complicated by SIRS
V. Gastrointestinal – Peptic ulcer, Gall bladder disease, liver abscess, Subdiaphragmatic abscess, Pancreatitis
VI. Pulmonary
I. Pleural disease (Pleuritis, Pleural effusion, Pneumothorax, Neoplasm)
II. Lung Parenchyma and vasculature (Pneumonia, Pulmonary embolism, Neoplasm)
VII. Cardiac – Acute coronary syndorome (ACS) (unstable angina, myocardial infarction), Pericarditis, Myocarditis, Stable
angina
VIII. Vascular – Acute aortic syndrome (AAS) (thoracic aortic dissection, intraluminal hematoma, aneurysm)
IX. Mediastinal structures – Lymphoma, Thymoma
X. Psychiatric
Complicated by Pericardial effusion, Anemia 17
Why history taking is important?

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Important points while taking chest pain history
The mnemonic ‘SOCRATES’ is helpful when taking a chest pain history.
• Site
• Onset
• Character
• Radiation
• Associated features
• Timing
• Exacerbating/relieving features
• Severity of pain

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Ischemic cardiac chest pain vs Noncardiac chest
pain

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Outline for today presentation

1. Constructing differential diagnosis of chest pain and dyspnoea

2. Cases approach

3. Guideline approach

4. Assessment questions

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• Mr. A, 65 year old man, has a history of well-controlled hypertension and diabetes mellitus. He has
been having symptoms for the last 4 months. He feels squeezing, substernal pressure while
climbing stairs to the elevated train he rides to work. The pressure resolves after about 5 minutes
of rest. He also occasionally feels the sensation during stressful periods at work. It is occasionally
associated with mild nausea and jaw pain. Medications are metformin, aspirin, and enalapril. His
BMI is 32. Vital signs are temperature, 37.0"C; BP 128/70 mm/Hg; Pulse 72, BPM; RR 16, breaths
per minute.

• Physical exam is entirely unremarkable except for mild, stable, peripheral neuropathy presumably
related to diabetes.

• The patient’s ECG is remarkable only for evidence of left ventricular hypertrophy with strain.
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Stable vs unstable angina vs NSTEMI vs STEMI

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 Criteria for diagnosing of angina pectoris
Angina is symptoma c reversible myocardial ischemia. Features

1. Constric ng / heavy discomfort to the chest, jaw, neck, shoulders, or arms

2. Symptoms brought on by exer on

3. Symptoms relieved within 5 minutes by rest or GTN

❖All 3 features = typical angina; 2 features = atypical angina; 0-1 features = non anginal chest pain

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Functional classification

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Investigations for angina pectoris
1. ECG - usually normal, may show ST depression; at or inverted T waves

2. Exercise ECG +/- Angiography +/- Func onal imaging (myocardial perfusion scin graphy, stress
echo, cardiac MRI)

3. Consider Echo and CXR

4. Blood tests - FBC, U&E, Crea nine, TFTs, Lipid, HbA1c

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Angina pectoris with normal coronary
artery
Vasospas c angina Takotsubo
Syndrome X
(Prinzmetal or variant cardiomyopathy
(microvascular angina)
angina) (Broken heart $)

Due to coronary artery Mechanism - unclear,

Mechanism - unclear
spasm acute emotional stress

Chest pain - at rest, Chest pain - typical stable

Chest pain - mimic AMI
resolve rapidly with GTN angina

Cardiac enzyme - normal Cardiac enzyme - normal Cardiac enzyme - raised

ECG - non specific ST-T

ECG - normal or ST
ECG - ST elevation changes
depression / elevation 30
Echo - LV apical dilatation
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Case 2
• Mrs. B is a 78-year-old woman with a history of hypertension who arrives at the emergency department by
ambulance complaining of chest burning that began 6 hours ago. Two hours a er ea ng, moderate (5/10) chest
discomfort developed. The pain begins In her mid-chest and radiates to her back. She ini ally a ributed the
pain to heartburn and used antacids. Despite mul ple doses over 3 hours, there was no relief. Over the last
hour, the pain became very severe (10/10) with radia on to her back and arms. The pain Is associated with
diaphoresis and shortness of breath. The pain is not pleuri c. She thinks that she is having a heart a ack. She
takes enalaprll for hypertension. She lives alone, is sedentary, and smokes 2 - 3 cigars each day for the past 50
years.
• On physical exam, she is in moderate distress. Vital signs are temperature, 37.0 C; BP, 156 / 90 mm Hg In both
arms; pulse, 100 bpm; RR. 22 breaths per minute. Head and neck exam including jugular and caro d pulsa ons
are normal. The lung exam is clear. Heart exam is notable for a normal S1 and S2 and a so , ejec on systolic
murmur. Abdominal exam is unremarkable with no tenderness, hepatosplenomegaly, or bruits.
• ECG shows ST depression in leads II, Ill, AVL, and V3-V6.

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Criteria for diagnosing of acute MI
1. A rise and fall of cardiac biomarkers (preferably troponin) with one of the following:

i. Symptoms of ischemia

ii. ECG changes consistent with new ischemia or Development of pathologic Q wave

iii. Imaging evidence of new loss of viable myocardium or myocardial func on

2. Pathologic evidence of MI

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 ECG Criteria for diagnosing of STEMI
1. ST eleva on > 1mm in ≥ 2 adjacent limb leads or > 2 mm in ≥ adjacent chest leads

2. New, or presumed new, le bundle branch block

3. Posterior changes: deep ST depression and tall R waves in leads V1 to V3

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Diagnostic limitations in ACS
• History - 25% have ‘atypical’ histories

• ECG - 55% of patient with AMI have normal 1st 12 lead ECG

• Conventional cardiac markers - normal for first 3 - 4 hours

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Case 3
• Mrs. C, 70 year old man with long history of untreated hypertension, non smoker came to
emergency department with complaint of sudden onset chest pain that began 3 hour ago. The
pain became severe and migrated to interscapular region. He has syncopal attack for few seconds
at the onset of chest pain. He thinks that he is having a heart attack.

• On examination, he is severe distress with sweating. His blood pressure is 200/110 mmHg, pulse
110 bpm, RR 26 breaths per minute. Head and neck exam including jugular and carotid pulsations
are normal. The lung exam is clear. Heart exam is notable for a normal S1 and S2 and a soft, early
diastolic murmur.

• ECG shows ST depression 1mm in II, III, aVF.

• Which next physical examination should be done in this patient?

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Diagnostic Hypotheses for Mr. C
• Next step for examination is measuring blood pressure both arms - unequal blood pressure

• Leading hypothesis - Thoracic aortic aneurysm dissection

• Active alternatives (must not miss) - AMI, Unstable angina

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Acute MI

Asymmetry of brachial, carotid or femoral pulses

Paraplegia

Acute abdomen, Renal failure

Limb ischemia
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Risk factors for aortic dissection
1. Hypertension (80%)
2. Atherosclerosis
3. Coarctation
4. Genetic: Marfan’s syndrome, Ehlers-Danlos syndrome
5. Fibromuscular dysplasia
6. Pregnancy (usually third trimester)
7. Trauma
8. Previous cardiac surgery: CABG, Aortic valve replacement
9. Iatrogenic: cardiac catheterization, intra-aortic balloon pumping

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Investigations for aortic dissection
1. ECG - left ventricular hypertrophy in hypertension or inferior acute MI changes
2. CXR - broadening of upper mediastinum and distortion of aortic knuckle (absent in 10% of cases),
left sided pleural effusion
3. Echo
• Transoesophageal echo better than transthoracic echo which can only image first 3-4 cm of
ascending aorta
• Doppler echo - aortic regurgitation, dilated aortic root, occasionally flap of the dissection
4. CT or MR angiography - gold standard (highly specific and sensitive)

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Case 4
• Mrs. D, 25 year old woman presented 1 week post delivery of her first baby. She has sharp left
sided chest pain and she is short of breath for 2 hours.

• On examination, blood pressure 90/60 mmHg, pulse 120/min, RR 25 breaths per minute. JVP
normal. Lung examination is clear. Heart examination is notable for normal S1 and S2.

• ECG shows sinus tachycardia.

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Constructing a differential diagnosis of chest pain
(best remembered anatomically from skin to internal organs)

I. Skin – Herpes zoster

II. Breast – Fibroadenoma, Mastitis, Gynaecomastia
III. Musculoskeletal – Costochondritis, Tietz syndrome, Precordial catch syndrome, Pectoral muscle strain, rib fracture,
cervical or thoracic spondylosis (C4-T6), myositis
IV. Esophageal – Spasm, Rupture, GERD, Esophagitis, Neoplasm
V. Gastrointestinal – Peptic ulcer, Gall bladder disease, liver abscess, Subdiaphragmatic abscess, Pancreatitis
VI. Pulmonary
I. Pleural disease (Pleuritis, Pleural effusion, Pneumothorax, Neoplasm)
II. Lung Parenchyma and vasculature (Pneumonia, Pulmonary embolism, Neoplasm)
VII. Cardiac – Acute coronary syndorome (ACS) (unstable angina, myocardial infarction), Pericarditis, Myocarditis, Stable
angina
VIII. Vascular – Acute aortic syndrome (AAS) (thoracic aortic dissection, intraluminal hematoma, aneurysm)
IX. Mediastinal structures – Lymphoma, Thymoma
X. Psychiatric
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Risk factors for pulmonary embolism

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Investigations for pulmonary embolism
1. ECG - often normal, sinus tachycardia, S1Q3T3 (right heart strain pattern), ST and T changes, RBBB
2. CXR

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Investigations for
pulmonary embolism
1. ECG - often normal, sinus tachycardia,
S1Q3T3 (right heart strain pattern), ST and
T changes, RBBB
2. CXR
3. D Dimer - elevated (high negative
predictive value

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Investigations for pulmonary embolism
1. ECG - often normal, sinus tachycardia, S1Q3T3 (right heart strain pattern), ST and T changes, RBBB
2. CXR
3. D Dimer - elevated (high negative predictive value)
4. Troponin I - may be elevated reflecting right heart strain
5. Echo - acute dilatation of right heart in massive PE +/- thrombus, can detect other differential
diagnosis like tamponade, aortic dissection, left ventricular failure
6. CTPA (CT pulmonary angiography) - gold standard (highly specific and sensitive)
7. V/Q scanning or V/Q SPECT (single photon emission CT) - when CTPA is contraindicated in renal
impairment.
8. Color Doppler USG of leg veins - if signs of DVT in limb are present (Homan’s sign / Dorsiflexion sign)

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Case 5
• Mr. E, 26 year old thin man, smoker, came with sudden onset of severe left sided sharp chest pain
and tachypnoeic.

• His CXR shows

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Case 6
• Ms. F is a 27-year-old woman presents to the emergency center complaining of retrosternal chest pain for the past 2 days. The pain is
constant, not associated with exertion, worsens when she takes a deep breath, and is relieved by sitting up and leaning forward. She
denies any shortness of breath, nausea, or diaphoresis.
• On examination, her temperature is 99.4°F, heart rate is 104 bpm, and blood pressure 118/72 mm Hg. She is sitting forward on the
stretcher, with shallow respirations. Her conjunctivae are clear and her oral mucosa is pink, with two aphthous ulcers. Her neck veins are
not distended; her chest is clear to auscultation and is mildly tender to palpation. Her heart rhythm is regular, with a harsh leathery
sound over the apex heard during systole and diastole. Her abdominal examination is benign, and her extremities show warmth and
swelling of the proximal interphalangeal (PIP) joints of both hands.
• Laboratory studies are significant for a white blood cell (WBC) count of 2100 cells/mm3, hemoglobin concentration 10.4 g/dL with mean
corpuscular volume (MCV) 94 fL, and platelet count 78,000/mm3. Her blood urea nitrogen (BUN) and creatinine levels are normal.
Urinalysis shows 10 to 20 WBCs and 5 to 10 red blood cells (RBCs) per high-powered field (hpf). A urine drug screen is negative.
• Chest x-ray is read as normal, with a normal cardiac silhouette and no pulmonary infiltrates or effusions. The electrocardiogram (ECG) is
shown in Figure
• What is the most likely diagnosis?

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Case 6 (cont:)
• Most likely diagnosis: Acute pericarditis as a consequence of SLE

• The classic ECG findings in acute pericarditis - diffuse ST-segment elevation in association with
PR-segment depression.
• The opposite findings (PR-segment elevation and ST-segment depression) are often seen in leads
aVR and V1.

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Acute pericarditis
Causes
1. Infection - viral (Coxsackie B virus, influenza), bacterial, tuberculosis
2. Inflammatory - Rheumatoid arthritis, SLE, Rheumatic fever
3. Other - Post MI, Uremia, Malignancy, Trauma

Clinical features
• Chest pain - retrosternal, radiates to shoulders and neck, aggravated by deep breathing,
movement, a change of position, exercise, swallowing
• Pericardial friction rub - high pitched, superficial scratching or crunching noise, produced by
movement of the inflamed pericardium, heard in both systole and diastole (Diagnostic sign)

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Case 7
• Mr. G is 42-year-old man complains of 2 days of worsening chest pain and dyspnea. Six weeks ago, he was
diagnosed with non-Hodgkin lymphoma with lymphadenopathy of the medias num, and he has been treated
with medias nal radia on therapy. His most recent treatment was 1 week ago. He has no other medical or
surgical history, and takes no medica ons. His chest pain is constant and unrelated to ac vity. He becomes
short of breath with minimal exer on.
• He is afebrile, heart rate is 115 bpm with a thready pulse, respiratory rate 22 breaths per minute, and blood
pressure 108/86 mm Hg. Systolic blood pressure drops to 86 mm Hg on inspira on. He appears uncomfortable
and is diaphore c. His jugular veins are distended to the angle of the jaw, and his chest is clear to ausculta on.
He is tachycardic, his heart sounds are faint, and no extra sounds are appreciated. The chest x-ray is shown in
Figure
• What is the most likely diagnosis?
• What is your next step in therapy?

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Case 7
• Most likely diagnosis: Pericardial effusion causing cardiac tamponade.
• Next therapeutic step: Urgent pericardiocentesis or surgical pericardial window

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 Acute - Beck triad

Chronic - present with

right heart failure,
Equalize Diastolic BP TB

Amyloidosis 56
Case 8
• Ms. H is 22 year old lady with complaints of central chest pain for past two days, came to
emergency department. She had no relevant past medical or medication history. She has
no family history of premature cardiovascular disease in her family members. She denied
trauma, recent travel or illness.

• On examination, there is tender swelling (2x2 cm) in her right second and third
costocartilages. There is no discoloration over the swelling.

• Her ECG, CXR show no abnormality.

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Constructing a differential diagnosis of chest pain
(best remembered anatomically from skin to internal organs)

I. Skin – Herpes zoster

II. Breast – Fibroadenoma, Mastitis, Gynaecomastia
III. Musculoskeletal – Costochondritis, Tietz syndrome, Precordial catch syndrome, Pectoral muscle strain, rib fracture,
cervical or thoracic spondylosis (C4-T6), myositis
IV. Esophageal – Spasm, Rupture, GERD, Esophagitis, Neoplasm
V. Gastrointestinal – Peptic ulcer, Gall bladder disease, liver abscess, Subdiaphragmatic abscess, Pancreatitis
VI. Pulmonary
I. Pleural disease (Pleuritis, Pleural effusion, Pneumothorax, Neoplasm)
II. Lung Parenchyma and vasculature (Pneumonia, Pulmonary embolism, Neoplasm)
VII. Cardiac – Acute coronary syndorome (ACS) (unstable angina, myocardial infarction), Pericarditis, Myocarditis, Stable
angina
VIII. Vascular – Acute aortic syndrome (AAS) (thoracic aortic dissection, intraluminal hematoma, aneurysm)
IX. Mediastinal structures – Lymphoma, Thymoma
X. Psychiatric
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Costochondritis vs Tietze’s syndrome

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Precordial catch syndrome or Texidor Twinge
• Site - precordial or central
• Onset - sudden onset
• Character - sharp
• Radiation - Localized
• Associated features - No associated symptoms
• Timing - occur at rest, lasting a couple of minutes
• Exacerbating/relieving features - exaggerated by deep breath
• Severity of pain - ??
• No physical findings
• Etiology - unknown / ? Prolong sitting in slumped position

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Outline for today presentation

1. Constructing differential diagnosis of chest pain and dyspnoea

2. Cases approach

3. Guideline approach

4. Assessment questions

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Outline for today presentation

1. Constructing differential diagnosis of chest pain and dyspnoea

2. Cases approach

3. Guideline approach

4. Assessment questions

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Question 1
The pain of myocardial ischemia
A. Is typically induced by exercise and relieved by rest T
B. Radiates to the neck and jaw but not the teeth F
C. Rarely lasts longer than 10 seconds after resting F
D. Is easily distinguished from oesophageal pain F
E. Invariably worsens as exercise continues T

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Question 2
In patient with central chest pain at rest
A. Intrascapular radiation suggests the possibility of aortic dissection T
B. Postural variation in pain suggests the possibility of pericarditis T
C. Chest wall tenderness is a typical feature of Tietze’s syndrome T
D. Relief of pain by nitrates excludes an esophageal cause F
E. Features of autonomic disturbance are specific to cardiac pain F

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Question 3
Typical features of acute pericarditis
A. Chest pain identical to that of myocardial infarction F
B. A friction rub that is best heard in axilla in mid expiration F
C. ST elevation on ECG with upward concavity T
D. Elevation of the serum creatinine kinase F
E. ECG changes that are only seen in the chest leads F

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Question 4
In 20 year old woman with acute pericarditis, the following disorders
should be excluded
A. Hodgkin’s disease T
B. Systemic lupus erythematosus T
C. Coxsackie A virus infection F
D. Acute rheumatic fever T
E. Rubella virus infection F

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Question 5
Characteristic features of dissecting aortic aneurysm include
A. Haemopericardium T
B. Acute paraparesis T
C. Interscapular back pain T
D. Early diastolic murmur T
E. Pleural effusion T

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Question 6
55 year old man with a history of poorly controlled hypertension presents
with history of sudden onset central chest pain. There are no diagnostic ECG
abnormalities and interval troponin concentration is not diagnostic of
myocardial infarction. What diagnostic should be confirmed or excluded first?
A. Anxiety
B. Aortic dissection
C. Myocarditis
D. Pericarditis
E. Pneumothorax

B 71
Question 7
A 55 year old man with type 2 diabetes presents with a 1 hour history of
severe central chest pain. Which of the following statements is true?
A. A normal baseline troponin and elevated 6 hour troponin level is
suspicious of myocardial infarction
B. A normal ECG excludes myocardial infarction
C. A normal initial troponin level excludes myocardial infarction
D. Failure of chest pain to resolve with nitrates confirms myocardial
infarction
E. T wave inversion on the ECG confirms myocardial infarction

A 72
Question 8
A 55 year old woman presents with a history of acute, severe, constricting central chest
pain associated with anterior ST segment elevation on the 12 lead ECG. She immediately
undergoes coronary angiography, which shows no evidence of coronary artery disesase and
no coronary occlusion. An Echocardiogram shows left ventricular apical dilatation with
normal left ventricular basal contraction. Which of the following factors is most likely to
have precipitated this illness?
A. Acute emotional stress
B. Cigarette smoking
C. Excessive alcohol consumption
D. Genetic factors
E. Viral infection

A 73
Question 9
An 18 year old man presents with sudden onset of sharp chest pain. The pain is made worse
by deep inspiration or lying down flat. It is relieved by sitting forward and taking shallow
breaths. He presents to the emergency department and an ECG is recorded because the
attending doctor suspects acute pericarditis. What is the most specific ECG changes in
pericarditis?
A. PR interval prolongation
B. PR segment depression
C. ST depression
D. ST elevation
E. T wave inversion

B 74
89$#,(+*%&:
A short young woman presents with severe chest pain, vomiting and sinus tachycardia. She
is in last trimester of pregnancy and has had normal blood pressure and observations at
antenatal care. She is admitted for observation but is later found collapsed and in cardiac
arrest. Despite attempts at resuscitation, mother and child die. Postmortem reveals an
aortic dissection. What is the most likely underlying cause for the dissection?
A. Coarctation of aorta
B. Intramural haemotoma
C. Marfan syndrome
D. Pregnancy
E. Undiagnosed hypertension

D 75
Take home points to remember

1. To recognize the differential diagnosis of chest pain and dyspnoea in general

2. To recognize the life threatening differential diagnosis of chest pain and dyspnoea

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Constructing a differential diagnosis of chest pain
(best remembered anatomically from skin to internal organs)

I. Skin – Herpes zoster

II. Breast – Fibroadenoma, Mastitis, Gynaecomastia
III. Musculoskeletal – Costochondritis, Tietz syndrome, Precordial catch syndrome, Pectoral muscle strain, rib fracture,
cervical or thoracic spondylosis (C4-T6), myositis
IV. Esophageal – Spasm, Rupture, GERD, Esophagitis, Neoplasm
V. Gastrointestinal – Peptic ulcer, Gall bladder disease, liver abscess, Subdiaphragmatic abscess, Pancreatitis
VI. Pulmonary
I. Pleural disease (Pleuritis, Pleural effusion, Pneumothorax, Neoplasm)
II. Lung Parenchyma and vasculature (Pneumonia, Pulmonary embolism, Neoplasm)
VII. Cardiac – Acute coronary syndorome (ACS) (unstable angina, myocardial infarction), Pericarditis, Myocarditis, Stable
angina
VIII. Vascular – Acute aortic syndrome (AAS) (thoracic aortic dissection, intraluminal hematoma, aneurysm)
IX. Mediastinal structures – Lymphoma, Thymoma
X. Psychiatric
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Constructing a differential diagnosis of dyspnoea
A. Lung
I. Airway - Suprathoracic airways (i.e. laryngeal edema), Intrathoracic airways (I.e. Asthma, COPD)
II. Alveoli (can fill with water, pus or blood) - Pulmonary edema (Heart failure, ARDS), Pneumonia, Pulmonary hemorrhage
III. Interstitial
i. Edema
ii. Inflammation - organic exposure (e.g. cotton), mineral exposures (e.g. asbestos), idiopathic disease (sarcoidosis, scleroderma)
iii. Infection (Pneumocystis)
iv. Malignancy (can occur all areas of lung)
IV. Pleural - Pneumothorax, Pleural effusion
V. Blood vessels - Pulmonary embolism, Pulmonary hypertension
B. Heart
I. Endocardium - VHD
II. Myocardium - HFrEF, HFpEF
III. Pericardium - tamponade, constrictive pericarditis
IV. Conduction system - Bradycardia (SSS), Heart block), Tachycardia (AF, SVT, VT)
V. Coronary artery - ischemia and infarction
C. Chest wall / Neuromuscular disease - Kyphoscoliosis, muscle weakness (myopathy, GBS), Obesity
D. Anemia
E. Metabolic disorders - acidosis (DKA), hyperthyroidism 78
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