Approach To A Patient Presenting With Chest Pain

Medical students during their posting in medical ward are being taught how to approach a patient who presents with a complain of chest pain.
Chest pain is a very common presenting system of a variety of medical conditions. These may be trivial or life threatening.
A brief summary is given below on how to approach to a case of Chest Pain

Causes Of Chest Pain: 

1. Cardiovascular Causes: 

• Angina
• Myocardial Infarction
• Acute aortic dissection
• Pericarditis

2. Gastrointestinal Causes:

• Reflux esophagitis
• Esophageal spasm
• Peptic ulcer disease

3. Pulmonary Causes:

• Pneumonia
• Pulmonary embolism
• Pneumothorax

4. Musculoskeletal Causes:

• Chest wall injuries
• Costochondritis
• Metastasis to ribs 
• Herpes zoster

5. Emotional

• Depression

History And Physical Examination: As for any case initial history and examination are an important aspect in reaching a diagnosis for a patient who presents with chest pain. 

1. Character of Pain: Ask about the nature and character of pain. 

Supplements That Can Reduce The Risk Of Falls In Elderly Patients.

Which of the following is associated with reducing the risk of falls in elderly patients?

A) Vitamin C
B) Vitamin D
C) Folate
D) Vitamin B12
E) Calcium

Answer and Discussion

An 80 Year Old Man Brought With A Noticeable Change In His Personality

An 80-year-old man is brought in by his wife. She complains her husband has had a noticeable change in his personality. He is impulsive and at times inappropriate with his behavior. Although he has difficulty naming objects, his memory, ability to calculate, and his visuospatial skills appear
to be intact.
The most likely diagnosis is

A) Alzhemier's Disease
B) Pick’s disease
C) Parkinson’s disease
D) Wilson’s disease
E) Lewy body dementia

Answer and Discussion

Comparing Clinical Presentation Of Hyperthyroidism In Elderly and Younger Patients.

When comparing middle-aged patients with hyperthyroidism to elderly patients with hyperthyroidism, elderly patients are more likely to have

A) Restlessness
B) Hyperactive appearance
C) Atrial fibrillation
D) Weight gain
E) Goiter

Answer and Discussion

American Heart Association (AHA) 2007 guidelines on the prevention of Infective endocarditis

A 37-year-old woman with a history of mitral valve prolapse and mitral regurgitation presents for evaluation. She reports no symptoms of shortness of breath or exercise intolerance. She plans to undergo health screening procedures, including dental exams for routine cleaning and filling of several caries, pelvic exam colonoscopy in the next year.
According to the American Heart Association (AHA) 2007 guidelines on the prevention of infective endocarditis, what should she receive prior to these procedures?

A) Amoxicillin 2 g PO.
B) Azithromycin 500 mg PO.
C) Clindamycin 600 mg PO.
D) Nothing.


Answer And Discussion

Regarding the BCG vaccine.....

Regarding the BCG vaccine, which of the following statements is true?

A) Foreign-born persons who received the BCG vaccine should never have a PPD administered.
B) The BCG vaccine is most efficacious for older adults, and children benefit much less from the vaccine.
C) A PPD in an individual with a remote history of BCG vaccine should be interpreted as if the BCG
had not been given.
D) The BCG vaccine is made from killed M. tuberculosis.

Answer And Discussion

Learning Compensated And Poorly Compensated Metabolic/ Respiratory Acidosis

While covering the ER, a 62-year-old female you have known for several years presents with her husband. Your patient appears very lethargic and is unable to give a coherent history. Her husband tells you that she began having stomach pain, nausea, and diarrhea 2 days ago. Although she has not been vomiting, she has been unable to drink or eat much due to nausea.
She takes furosemide for edema and albuterol/ipratropium for COPD.
She smokes a pack of cigarettes per day.
On physical examination, her respiratory rate is 30, pulse 104, blood pressure 112/64, and temperature 37.9◦C.
She is lethargic and disoriented.
Oral mucosa is dry.
Her lungs show diminished air movement bilaterally.
Her abdomen is diffusely tender, but there is no rebound.
Rectal exam is negative for occult blood.
The first laboratory test you have available is a room air arterial blood gas:

•  pH 7.12, 
• PaCO2 33 mm Hg,
• PaO2 80 mm Hg,
• HCO3 10 mEq/L, and 
• oxygen saturation 92%. 

This blood gas is most consistent with which of the following processes?

A) Compensated metabolic acidosis.
B) Compensated respiratory acidosis.
C) Poorly compensated metabolic acidosis.
D) Poorly compensated respiratory acidosis.

Answer And Discussion:

Causes Of Nephrotic Syndrome

Nephrotic syndrome is not a specific disease entity but can be the end result of a number of processes. Which of the following cause nephrotic syndrome?

A) Diabetes.
B) Minimal change disease.
C) Amyloidosis.
D) Systemic lupus erythematosus.
E) All of the above.

Answer And Discussion:

Tinnitus And Its Cause

The most common cause of tinnitus is

A) Infection (otitis media)
B) Chronic use of salicylates
C) Sensorineural hearing loss
D) Hypertension
E) Acoustic neuroma

Answer and Discussion

Depression And Other Co Morbidities

A 56 year old man was admitted to coronary care unit after a myocardial infarction. At present he is clinically stable. He mentions to his treating physician that he has been suffering from depression in the past but has never seeked treatment. On further questioning he said he suffers from insomnia, depressed mood, lack of concentration and loss of interest in activities like playing golf which once he enjoyed. 

Which of the following statements regarding depression is true?

A. The patient is not at risk of committing suicide.

B. Genetics play no role on depression

C. The incidence of depression decreases with age.

D. The mortality 6 months after MI is 5 times higher in depressed patients than in non depressed patients. 

Osteomyelitis - Case Discussion And Questions

Osteomyelitis in adults almost always presents in a patient with diabetes, peripheral arterial disease, or both with an ulcer or soft tissue infection. You can also think about osteomyelitis in patients with direct trauma and a history of orthopedic surgery , but the case with diabetes and peripheral vascular disease is more likely to show up on exam.

Diagnostic Testing:

• Best initial test : Plain X ray
• Best second test ( if X ray is negative and there is clinical suspicion) : MRI
• Most accurate test: bone biopsy and culture

The patient losses almost 50 % of the bone calcium before the x ray becomes abnormal. Although it may take up to 2 weeks for osteomyelitis to become severe enough to show on X ray , the X ray is still the best test. 

Question: 

Which of the following is the earliest finding of osteomyelitis on X ray?

A. Periosteal elevation

B. Involucrum

C. Sequestrum

D. Punched out lesions

E. Fracture

Managing A Case Of Dog Bite

A 50-year-old man is brought to you in ED after being bitten by a stray dog. The bite was unprovoked and is on the abdomen. The patient has no other health history of note and has not taken antibiotics for over a year. You irrigate the wound and are deciding about closure. There is a 3-cm laceration on the abdomen.

All of the following are true about dog bites EXCEPT:

A) They tend to be primarily crush-type injuries.
B) In general, the infection rate is similar to a laceration from any other mechanism (e.g., knife cut),
except on the hands and feet.
C) A common organism in infected dog bites is Staphylococcus aureus.
D) Primary closure of dog bite wounds is an acceptable
option (except perhaps on the hands and feet).
E) They always require antibiotics.

Answer And Discussion

A Patient on Anti Tuberculous Therapy Presents With Seizures

A 45 year old woman is brought to the emergency department with seizures. Her daughter informed the doctor that she has been on antituberculosis therapy for last 2 months, There was no previous history of seizures or epilepsy.
The best therapy for seizures secondary to isoniazid ingestion is:

A) Lorazepam.
B) Phenytoin.
C) Pyridoxine.
D) Thiamine.
E) Phenobarbital.

Answer And Discussion

A Case Of Gynecomastia

A 60-year-old alcoholic man, currently being treated for gastritis, presents to the office with painful breasts that appear enlarged. The most likely cause is

A) Breast cancer
B) Excessive calcium carbonate ingestion
C) Omeprazole use
D) Trauma
E) Prolactinoma

Answer And Discussion:
The answer is C. (Omeprazole use)

Gynecomastia is a condition characterized by enlargement of the breasts in men. It occurs when there is hypertrophy of breast tissue beneath the areola. In young adolescents, it is a natural response to the body’s hormones. During this time, the breast may be tender. Patients and their parents should be reassured this is a natural response and will eventually resolve (usually within 3 years).

Screening For Prostate Cancer

A 60-year-old man presents to your office inquiring about prostate cancer screening. Choose the correct statement:

A) PSA is the gold standard test for prostate cancer screening.
B) PSA should be checked annually starting at 50 years of age to screen for prostate cancer.
C) PSA can produce false-positive results, which can be associated with negative psychological effects.
D) Men who have false-positive test are less likely to have additional testing.
E) The USPSTF recommends PSA testing to screen for prostate cancer at age 60.

Answer And Discussion:

Cerebral Palsy

An 18 month old child attends the child development center for a thorough assessment with suspected diagnosis of cerebral palsy. Which of the following clinical features would be most likely to suggest an alternative diagnosis?
Select ONE answer Only

A. Dystonia
B. Family history of cerebral palsy
C. Hyperkinesia
D. Prematurity
E. Spasticity

Correct Answer is option B:  Family history of cerebral palsy

Cerebral Palsy:

Cerebral Palsy is a descriptive term which has been defined as a group of permanent disorders of movement and posture causing activity limitation that are attributed to non progressive disturbances that occurred in the developing fetal or infant brain.