Chief Complaint: A 75-year-old female reports experiencing pain in her chest while walking up steps today.

Full Answer Section

• • Where exactly does the pain radiate, if anywhere? (e.g., jaw, back, arms – even though she denies arm pain, re-confirming is important).
  • How long does the pain episode typically last?
  • How frequently have you experienced this pain before? Is this a new symptom?
  • What were you doing immediately before the pain started this morning?
• Associated Symptoms:
  • Have you experienced any shortness of breath, even mild?
  • Any palpitations, dizziness, lightheadedness, or near-syncope?
  • Any nausea, vomiting, or sweating?
  • Any unusual fatigue or weakness, especially in women this can be an atypical cardiac symptom.
  • Any cough?
• Cardiovascular History in Detail:
  • Re-confirm history of hypertension: How long have you had it? Are you currently taking medication? Is it well-controlled?
  • Specifically ask about any history of:
    • Angina or prior episodes of chest pain.
    • Myocardial infarction (heart attack).
    • Coronary artery disease (CAD).
    • Atrial fibrillation or other arrhythmias.
    • Heart failure.
    • High cholesterol (hyperlipidemia).
  • Family history of cardiovascular disease, especially premature CAD (before age 55 in male relatives, before age 65 in female relatives).
• Other Medical History:
  • History of diabetes mellitus?
  • History of gastroesophageal reflux disease (GERD) or hiatal hernia?
  • History of anxiety or panic disorders?
  • Current medications, including over-the-counter drugs and supplements.
  • Allergies.
• Social History:
  • Smoking history (current, former, pack-years).
  • Alcohol consumption.
  • Stress levels.

2. What other objective findings would you look for?

During the physical examination, I would pay close attention to the following:

• Cardiovascular:
  • Auscultate heart sounds carefully for any new murmurs, rubs, or gallops that might have developed since the initial assessment.
  • Check for any signs of peripheral edema, although she denies leg swelling. Examine both lower extremities.
  • Palpate peripheral pulses (radial, dorsalis pedis, posterior tibial) for strength and equality.
  • Listen for any carotid bruits again, ensuring careful auscultation.
• Respiratory:
  • Assess for any signs of increased work of breathing, even if she reports it as unlabored. Look for accessory muscle use or nasal flaring.
  • Percuss the chest for any areas of dullness or hyperresonance.
• Gastrointestinal:
  • Palpate the abdomen for any tenderness, especially in the epigastric region, which could suggest a gastrointestinal source of pain.
• General Appearance:
  • Note her overall demeanor. Is she anxious, diaphoretic (sweaty), or pale?
• Skin:
  • Assess skin color and temperature for any signs of poor perfusion.

3. What diagnostic exams do you want to order?

Given the patient's age, symptoms, and risk factors (hypertension, obesity), a cardiac workup is essential. I would order the following:

• Electrocardiogram (ECG/EKG): This is the most crucial initial test to look for signs of acute ischemia, injury, or infarction, as well as arrhythmias or conduction abnormalities. Even if the initial ECG is normal, serial ECGs may be needed if suspicion remains high.
• Cardiac Biomarkers (Troponin I or T, CK-MB): These blood tests help detect myocardial damage. Troponin is highly specific for cardiac muscle injury and is the preferred biomarker. Serial measurements over several hours are often necessary as it can take time for these markers to rise.
• Complete Blood Count (CBC): To rule out anemia or infection as contributing factors to her symptoms.
• Basic Metabolic Panel (BMP): To assess electrolyte levels, renal function, and glucose, which can influence cardiac health.
• Chest X-ray (CXR): To evaluate for pulmonary causes of chest pain (e.g., pneumonia, pneumothorax) and to assess cardiac size and lung congestion.
• Consideration for further cardiac testing based on initial results and ongoing suspicion:
  • Continuous Cardiac Monitoring: To detect any intermittent arrhythmias.
  • Echocardiogram: To assess cardiac structure and function (e.g., ejection fraction, wall motion abnormalities, valvular disease).
  • Stress Test (Exercise or Pharmacological): To evaluate for inducible ischemia if the initial ECG and biomarkers are negative and the patient becomes asymptomatic. However, this would be deferred in the acute setting of ongoing or recent chest pain until acute coronary syndrome is ruled out.
  • Coronary Angiography: If there is high suspicion for acute coronary syndrome or significant findings on non-invasive testing.

4. Name 3 differential diagnoses based on this patient presenting symptoms?

1. Acute Coronary Syndrome (ACS) - Unstable Angina or Non-ST-Segment Elevation Myocardial Infarction (NSTEMI):
2. Gastroesophageal Reflux Disease (GERD) or Esophagitis:
3. Stable Angina Pectoris:

5. Give rationales for each differential diagnosis.

• Acute Coronary Syndrome (ACS) - Unstable Angina or Non-ST-Segment Elevation Myocardial Infarction (NSTEMI):

  • Rationale: The central chest pain, described as an ache or burning sensation, especially occurring with exertion (walking up steps), is a classic symptom of myocardial ischemia. Even though the pain has decreased and she denies arm pain, atypical presentations are common in women and the elderly. Her history of hypertension is a significant risk factor for coronary artery disease. The fact that she couldn't sleep the previous night could also be related to nocturnal angina or pre-infarction symptoms. While her vital signs are currently stable, this doesn't rule out ACS. The initial pain intensity of 8/10 suggests a significant event. NSTEMI would involve myocardial damage detectable by elevated troponin levels, while unstable angina involves ischemic pain without significant biomarker elevation.

• Gastroesophageal Reflux Disease (GERD) or Esophagitis:

  • Rationale: The burning sensation in the center of the sternum can be a symptom of GERD, where stomach acid refluxes into the esophagus, causing irritation. Poor dentition and multiple carries can sometimes be associated with dietary factors that might contribute to GERD. The improvement in pain could be related to positional changes or the passage of time. However, exertional pain is less typical for GERD, and cardiac causes need to be ruled out first, especially in this age group with hypertension.

• Stable Angina Pectoris:

  • Rationale: The exertional chest pain that subsides with rest (implied by the decrease in pain intensity) is characteristic of stable angina. This occurs when the coronary arteries are narrowed, leading to insufficient blood flow to the heart muscle during increased demand (like climbing stairs). Her history of hypertension increases her risk for underlying coronary artery disease. However, the report of not being able to sleep due to the pain and the initial high pain score (8/10) raise concern for a more unstable pattern, necessitating investigation for ACS. Stable angina is typically predictable and relieved by rest or nitroglycerin (which she hasn't mentioned using).

Given the potential for a life-threatening cardiac event, Acute Coronary Syndrome (ACS) should be the highest priority differential diagnosis until proven otherwise. Prompt and thorough evaluation with an ECG and cardiac biomarkers is crucial.

Sample Answer

This is a concerning presentation of chest pain in a 75-year-old female, even though the pain has decreased in intensity. Given her age and the nature of the pain (central, burning/aching, exertional), cardiac etiology needs to be strongly considered and ruled out.

Here are my responses to your questions:

1. What other subjective data would you obtain?

To get a more complete picture, I would ask the patient the following additional questions:

• Detailed Pain Characterization:
  • Can you describe the pain more precisely? Is it sharp, dull, pressure-like, squeezing, stabbing?
  • Does anything else make the pain better or worse (besides rest)? For example, eating, lying down, specific movements?