Chest Pain Evaluation — MCQs

10 questions

After a successful Total Hip Replacement a 59 year old patient developed severe chest pain. Echocardiography revealed reduced wall motion of right ventricle with slow flow across the tricuspid valve. Which of the following is most likely diagnosis?

Becks triad is seen in

Sitaram a 40-year old man, met with an accident and comes to emergency department with engorged neck veins, pallor, rapid pulse and chest pain Diagnosis is -

A 50-year-old male presents with sharp, localized chest pain, worse with deep breaths and relieved by sitting up. ECG is normal. What is the most likely diagnosis?

Which is the best test to detect pulmonary embolism?

Which of the following conditions is not typically associated with back pain?

Which of the following statements regarding lymphoedema are correct? 1. Patients experience constant dull ache and even severe pain sometimes 2. Manual lymphatic drainage has a role 3. Primary lymphoedema is caused by congenital lymphatic dysplasia 4. Nonne Milroy's disease is a type of primary lymphoedema Select the correct answer using the code given below:

Which of the following is not a clinical feature of Bronchiectasis?

A 22-year-old male with a known history of sickle cell disease presents with sudden onset chest pain, dyspnea, and cyanosis. What is the most likely diagnosis and the immediate treatment?

Q10

A 25-year-old man complains of low backache, decreased lumbar movements, morning stiffness, which clinical examination will further help:

Chest Pain Evaluation Indian Medical PG Practice Questions and MCQs

Question 1: After a successful Total Hip Replacement a 59 year old patient developed severe chest pain. Echocardiography revealed reduced wall motion of right ventricle with slow flow across the tricuspid valve. Which of the following is most likely diagnosis?

A. Right ventricular infarction
B. Dilated cardiomyopathy
C. Pulmonary embolism (Correct Answer)
D. Aortic dissection

Explanation: ***Pulmonary embolism*** - A **pulmonary embolism** is a common and serious complication following **total hip replacement surgery** due to increased risk of deep vein thrombosis [1]. - The echocardiographic findings of **reduced right ventricular wall motion** with **slow flow across the tricuspid valve** are classic signs of acute right ventricular strain due to increased pulmonary artery pressure caused by a pulmonary embolism [2]. *Right ventricular infarction* - While RV infarction can cause chest pain and RV dysfunction, it is less common in this clinical context and typically associated with **inferior myocardial infarction** affecting the right coronary artery [1]. - The combination of recent surgery and RV strain points away from primary infarction as the most likely cause. *Dilated cardiomyopathy* - **Dilated cardiomyopathy** is a chronic condition characterized by dilation and impaired contraction of one or both ventricles, usually presenting with progressive heart failure symptoms. - It would not typically manifest as acute severe chest pain and isolated RV dysfunction suddenly after surgery in a patient without prior history. *Aortic dissection* - **Aortic dissection** presents with sudden, severe, tearing chest or back pain, often with pulse deficits or signs of malperfusion [1]. - While it causes chest pain, the echocardiographic findings of isolated right ventricular dysfunction are not characteristic of aortic dissection.

Question 2: Becks triad is seen in

A. Cardiac tamponade (Correct Answer)
B. Restrictive cardiomyopathy
C. Constrictive pericarditis
D. None of the options

Explanation: ***Cardiac tamponade*** - **Beck's triad** is a set of three clinical signs associated with acute cardiac tamponade: **hypotension**, **jugular venous distension (JVD)**, and **muffled heart sounds**. [1] - These signs result from the accumulation of fluid in the pericardial sac, which compresses the heart and impairs its ability to fill. [1] *Constrictive pericarditis* - While it can manifest with JVD and signs of right heart failure, **muffled heart sounds** and acute **hypotension** as part of Beck's triad are not typical for its chronic nature. [2] - It involves a rigid, fibrotic pericardium that restricts diastolic filling, often with a **pericardial knock** rather than muffled sounds. [2] *Restrictive cardiomyopathy* - This condition involves impaired ventricular relaxation and filling, leading to signs of heart failure, including JVD. [3] - However, it does not typically present with the acute, severe **hypotension** or **muffled heart sounds** characteristic of cardiac tamponade. [3] *None of the options* - This option is incorrect as cardiac tamponade is the condition associated with Beck's triad.

Question 3: Sitaram a 40-year old man, met with an accident and comes to emergency department with engorged neck veins, pallor, rapid pulse and chest pain Diagnosis is -

A. Pulmonary laceration (lung injury)
B. Splenic rupture (abdominal trauma)
C. Hemothorax (blood in the pleural cavity)
D. Cardiac tamponade (fluid accumulation in the pericardium) (Correct Answer)

Explanation: ***Cardiac tamponade (fluid accumulation in the pericardium)*** - **Engorged neck veins (elevated JVP)**, **pallor** (due to decreased cardiac output), and a **rapid pulse** ("pulsus paradoxus" or tachycardia from compensatory mechanisms) in the context of trauma are classic signs of **cardiac tamponade**. - **Chest pain** can result from the acute compression of the heart, leading to reduced ventricular filling and cardiac output. *Pulmonary laceration (lung injury)* - A pulmonary laceration would primarily present with **respiratory distress**, **hemoptysis**, and potential **air leak syndromes** (e.g., pneumothorax), not typically engorged neck veins as a primary sign. - While it can cause chest pain and rapid pulse, it doesn't explain the combination of engorged neck veins and significant cardiovascular compromise seen here without other prominent respiratory symptoms. *Splenic rupture (abdominal trauma)* - Splenic rupture typically presents with **left upper quadrant abdominal pain**, **abdominal tenderness**, and signs of **hypovolemic shock** (pallor, rapid pulse, hypotension), but not generally engorged neck veins. - The primary location of trauma and symptoms would be abdominal, not chest pain and engorged neck veins. *Hemothorax (blood in the pleural cavity)* - A hemothorax would cause **chest pain**, **dyspnea**, **diminished breath sounds** on the affected side, and signs of **hypovolemic shock** if severe (pallor, rapid pulse). - However, it typically leads to **collapsed neck veins** due to hypovolemia, rather than engorged neck veins, unless there's a co-existing tension pneumothorax or cardiac tamponade.

Question 4: A 50-year-old male presents with sharp, localized chest pain, worse with deep breaths and relieved by sitting up. ECG is normal. What is the most likely diagnosis?

A. Pneumothorax
B. Myocardial infarction
C. Pleuritis
D. Pericarditis (Correct Answer)

Explanation: ***Pericarditis*** - The classic presentation of **sharp, localized chest pain** that is **worse with deep breaths** and **relieved by sitting up and leaning forward** is highly characteristic of pericarditis [2]. - A **normal ECG** makes other cardiac causes less likely, supporting the diagnosis of pericarditis, which can have diffuse ST elevation or PR depression as ECG findings, but a normal ECG doesn't rule it out, especially early on [2]. *Pneumothorax* - While pneumothorax can cause **sharp chest pain** and be **respiratory variation**, it is typically associated with **dyspnea** and **diminished breath sounds** on examination, which are not mentioned here. - The pain relief with sitting up is not characteristic of pneumothorax. *Myocardial infarction* - **Myocardial infarction** pain is typically described as a **heavy, pressure-like sensation**, often radiating to the arm, jaw, or back, and is usually not relieved by position changes [1]. - A **normal ECG** makes acute myocardial infarction less likely, though it does not entirely rule out non-ST elevation myocardial infarction (NSTEMI). *Pleuritis* - **Pleuritis** also causes **sharp, pleuritic chest pain** that worsens with deep inspiration or coughing. - However, the classic relief with **sitting up and leaning forward** is more specific to pericarditis than pleuritis.

Question 5: Which is the best test to detect pulmonary embolism?

A. D dimer assay
B. MRI
C. Ventilation Perfusion scan
D. CT with IV contrast (Correct Answer)

Explanation: ***CT with IV contrast*** - **CT pulmonary angiography (CTPA)** is the **gold standard** for diagnosing pulmonary embolism due to its high sensitivity and specificity [1]. - It directly visualizes the **pulmonary arteries** and can detect emboli, making it the most definitive imaging test [1]. *D dimer assay* - A **negative D-dimer** can effectively **rule out PE** in low-to-intermediate probability patients, but a positive result is non-specific and requires further investigation. - It is a screening test with **poor specificity** in many clinical situations, such as surgery, trauma, cancer, or pregnancy, where D-dimer levels can be elevated for other reasons. *MRI* - **Magnetic resonance angiography (MRA)** can be used for PE diagnosis, particularly in patients unable to receive iodinated contrast or radiation. - However, it has **lower spatial resolution** and is generally less available and slower than CTPA, making it a second-line option. *Ventilation Perfusion scan* - A **V/Q scan** measures airflow (ventilation) and blood flow (perfusion) in the lungs to detect mismatches suggestive of PE [1]. - While useful, particularly in patients with **renal insufficiency** or **contrast allergy**, it often yields indeterminate results and is less sensitive than CTPA for definitive diagnosis [1].

Question 6: Which of the following conditions is not typically associated with back pain?

A. Renal colic
B. Aortic dissection
C. Pancreatitis
D. Pneumothorax (Correct Answer)

Explanation: ***Pneumothorax*** - A **pneumothorax** is the presence of air or gas in the pleural space, which can cause sudden chest pain and shortness of breath [2], . - While it causes significant pain, this pain is typically localized to the **chest wall** and does not usually radiate to the back as a primary symptom [2]. *Renal colic* - **Renal colic** is characterized by severe, spasmodic pain caused by the passage of a kidney stone. - This pain classically radiates from the **flank to the groin**, often associated with severe back pain due to the retroperitoneal location of the kidneys. *Pancreatitis* - **Pancreatitis** involves inflammation of the pancreas, which can cause severe epigastric pain [1]. - This pain is well-known to **radiate to the back** and is often described as boring or dull [1]. *Aortic dissection* - An **aortic dissection** is a critical condition where the inner layer of the aorta tears, allowing blood to surge between the layers. - It typically presents with a sudden onset of severe **"tearing" or "ripping" pain** that often radiates to the back, particularly depending on the location of the dissection (e.g., descending aorta).

Question 7: Which of the following statements regarding lymphoedema are correct? 1. Patients experience constant dull ache and even severe pain sometimes 2. Manual lymphatic drainage has a role 3. Primary lymphoedema is caused by congenital lymphatic dysplasia 4. Nonne Milroy's disease is a type of primary lymphoedema Select the correct answer using the code given below:

A. 1 and 2 only
B. 1, 2, 3 and 4 (Correct Answer)
C. 3 and 4 only
D. 1, 2 and 3 only

Explanation: ***1, 2, 3 and 4*** - All four statements are correct regarding lymphoedema. Patients often experience **constant dull ache and severe pain** due to the swelling and tissue changes. - **Manual lymphatic drainage (MLD)** is a key component of complete decongestive therapy for lymphoedema, aiming to reduce swelling and improve lymphatic flow. **Primary lymphoedema** is indeed caused by **congenital lymphatic dysplasia**, which refers to abnormalities in lymphatic system development from birth. **Milroy's disease** (also known as Nonne-Milroy disease) is a specific type of primary lymphoedema characterized by early-onset lymphatic dysfunction. *1 and 2 only* - This option is incomplete as statements 3 and 4 are also correct. - It correctly identifies the role of manual lymphatic drainage and the presence of pain in lymphoedema but omits other accurate facts. *3 and 4 only* - This option is incomplete as statements 1 and 2 are also correct. - While correctly identifying the nature of primary lymphoedema and Milroy's disease, it misses other important aspects of lymphoedema. *1, 2, and 3 only* - This option is incomplete because statement 4, concerning Milroy's disease as a type of primary lymphoedema, is also correct. - It provides correct information about pain, MLD, and the cause of primary lymphoedema but omits a specific example of primary lymphoedema.

Question 8: Which of the following is not a clinical feature of Bronchiectasis?

A. Hemoptysis
B. Chest pain
C. Night sweats (Correct Answer)
D. Productive cough

Explanation: ***Night sweats*** - While **night sweats** can be present in chronic infections, they are not considered a primary or defining clinical feature directly associated with the pathology of bronchiectasis itself. - They are more commonly linked with systemic conditions like **tuberculosis** or malignancy, which would require alternative diagnostic pathways. *Hemoptysis* - **Hemoptysis** (coughing up blood) is a common and often alarming symptom of bronchiectasis due to the inflammation and damage to the bronchial walls and underlying vasculature [1]. - Blood vessels in damaged airways are prone to rupture, leading to bleeding, which can range from blood-streaked sputum to massive hemorrhage [1]. *Chest pain* - **Chest pain** can occur in bronchiectasis, often related to the chronic cough, pleural inflammation, or musculoskeletal strain from persistent coughing. - It can also be a symptom if there's an associated infection or inflammation extending to the pleura. *Productive cough* - A **chronic productive cough** with significant amounts of purulent sputum is the hallmark symptom of bronchiectasis [1]. - This is due to the impaired mucociliary clearance and chronic infection within the dilated, damaged airways .

Question 9: A 22-year-old male with a known history of sickle cell disease presents with sudden onset chest pain, dyspnea, and cyanosis. What is the most likely diagnosis and the immediate treatment?

A. Diagnosis: Acute chest syndrome; Treatment: Provide oxygen and hydration (Correct Answer)
B. Diagnosis: Pulmonary embolism; Treatment: Start anticoagulation
C. Diagnosis: Asthma exacerbation; Treatment: Use bronchodilators
D. Diagnosis: Pneumonia; Treatment: Administer antibiotics

Explanation: Everything in the prompt remains as is, but with citations added: ***Diagnosis: Acute chest syndrome; Treatment: Provide oxygen and hydration*** - The sudden onset of chest pain, dyspnea, and cyanosis in a patient with **sickle cell disease** is highly indicative of **acute chest syndrome (ACS)**, a common and serious complication [1]. - Immediate management involves supportive care including **oxygen supplementation** to combat hypoxemia and **adequate hydration** to prevent further sickling and improve blood flow [1]. *Diagnosis: Pulmonary embolism; Treatment: Start anticoagulation* - While pulmonary embolism can cause similar symptoms, it is less likely to present with **cyanosis** as a primary feature in sickle cell disease compared to ACS. - Although anticoagulation is the treatment for PE, it is not the immediate priority for a patient with suspected ACS, where **oxygen** and **hydration** are crucial [1]. *Diagnosis: Asthma exacerbation; Treatment: Use bronchodilators* - Asthma exacerbation would be characterized by **wheezing** and a history of asthma, which are not mentioned in the patient's presentation. - While bronchodilators are the treatment for asthma, they would not address the underlying **sickling crisis** or its pulmonary manifestations [1]. *Diagnosis: Pneumonia; Treatment: Administer antibiotics* - Pneumonia can cause chest pain and dyspnea, but **cyanosis** suggests a more acute and severe oxygenation issue beyond typical pneumonia at onset. - Although antibiotics are the treatment for bacterial pneumonia, they are not the immediate first-line intervention if ACS is suspected, especially given the prompt needs for **oxygen** and **hydration** [1].

Question 10: A 25-year-old man complains of low backache, decreased lumbar movements, morning stiffness, which clinical examination will further help:

A. Chest expansion (Correct Answer)
B. Head circumference
C. Plantar arch
D. Hyperextension of joints

Explanation: ***Chest expansion*** - In **ankylosing spondylitis** (suggested by the young age, low backache, decreased lumbar movements, and morning stiffness), **chest wall restriction** is common due to enthesitis of the costovertebral and sternocostal joints [1]. - Measuring **chest expansion** helps assess the degree of involvement and progression of the disease [1]. *Head circumference* - This measurement is typically used in the assessment of **pediatric growth and development** or certain neurological conditions, not relevant for adult back pain. - It provides no diagnostic information for conditions affecting the spine and joints. *Plantar arch* - Assessment of the **plantar arch** relates to foot mechanics and conditions like **pes planus (flat feet)** or **pes cavus (high arches)**. - While foot problems can cause pain, they are not directly linked to the typical presentation of inflammatory spondyloarthropathies affecting the lumbar spine. *Hyperextension of joints* - **Joint hyperextension** (hypermobility) is characteristic of conditions like **Ehlers-Danlos syndrome** or other hypermobility syndromes [2]. - The patient's symptoms of decreased lumbar movements and stiffness are actually the opposite of hypermobility.

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