Red flags in chest pain — MCQs

10 questions

A 36-year-old man presents to the physician with difficulty in breathing for 3 hours. There is no history of chest pain, cough or palpitation. He is a chronic smoker and underwent elective cholecystectomy one month back. There is no history of chronic or recurrent cough, wheezing or breathlessness. His temperature is 38.2°C (100.8°F), pulse is 108/min, blood pressure is 124/80 mm Hg, and respirations are 25/min. His arterial oxygen saturation is 98% in room air as shown by pulse oximetry. After a detailed physical examination, the physician orders a plasma D-dimer level, which was elevated. A contrast-enhanced computed tomography (CT) of the chest shows a filling defect in a segmental pulmonary artery on the left side. Which of the following signs is most likely to have been observed by the physician during the physical examination of this patient’s chest?

A 74-year-old woman is brought by ambulance to the emergency department and presents with a complaint of excruciating chest pain that started about 45 minutes ago. The patient was sitting in the garden when she 1st noticed the pain in the upper abdomen. The pain has persisted and now localizes underneath of the sternum and the left shoulder. Milk of magnesia and aspirin were tried with no relief. The patient had previous episodes of chest pain that were of lesser intensity and rarely lasted more than 10 minutes. She is diabetic and has been managed for hypertension and rheumatoid arthritis in the past. On examination, the patient is breathless and sweating profusely. The vital signs include blood pressure 140/90 mm Hg and heart rate 118/min. The electrocardiogram (ECG) shows Q waves in leads V2 and V3 and raised ST segments in leads V2, V3, V4, and V5. Laboratory studies (including cardiac enzymes at 6 hours after admission show: Hematocrit 45% Troponin T 1.5 ng/mL Troponin I 0.28 ng/mL Creatine kinase (CK)-MB 0.25 ng/mL The patient is admitted and started on analgesia and reperfusion therapy. She shows initial signs of recovery until the 6th day of hospitalization when she starts vomiting and complaining of dizziness. Physical examination findings at this time included heart rate 110/min, temperature 37.7°C (99.9°F), blood pressure 90/60 mm Hg. Jugular venous pressure is 8 cm. A harsh pansystolic murmur is present at the left lower sternal border. ECG shows sinus tachycardia and ST-segment elevation with terminal negative T waves. Laboratory studies show: Hematocrit 38% Troponin T 1.15ng/mL Troponin I 0.18 ng/mL CK-MB 0.10 ng/mL Which of the following best explains the patient's current clinical condition?

A 17-year-old girl is admitted to the emergency department with severe retrosternal chest pain. The pain began suddenly after an episode of self-induced vomiting following a large meal. The patient’s parents say that she is very restricted in the foods she eats and induces vomiting frequently after meals. Vital signs are as follows: blood pressure 100/60 mm Hg, heart rate 98/min, respiratory rate 14/min, and temperature 37.9℃ (100.2℉). The patient is pale and in severe distress. Lungs are clear to auscultation. On cardiac examination, a crunching, raspy sound is auscultated over the precordium that is synchronous with the heartbeat. The abdomen is soft and nontender. Which of the following tests would most likely confirm the diagnosis in this patient?

A 55-year-old man presents to the emergency department for chest pain. He states that the pain started last night and has persisted until this morning. He describes the pain as in his chest and radiating into his back between his scapulae. The patient has a past medical history of alcohol abuse and cocaine abuse. He recently returned from vacation on a transatlantic flight. The patient has smoked 1 pack of cigarettes per day for the past 20 years. His temperature is 99.5°F (37.5°C), blood pressure is 167/118 mmHg, pulse is 120/min, and respirations are 22/min. Physical exam reveals tachycardia and clear air movement bilaterally on cardiopulmonary exam. Which of the following is also likely to be found in this patient?

A 65-year-old man with hypertension and type 2 diabetes mellitus is brought to the emergency department 20 minutes after the onset of severe anterior chest pain and shortness of breath. He has smoked one pack of cigarettes daily for 30 years. He appears distressed. His pulse is 116/min, respirations are 22/min, and blood pressure is 156/88 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. A grade 3/6, high-pitched, blowing, diastolic murmur is heard over the right upper sternal border. Which of the following is the most likely cause of this patient's symptoms?

A 33-year-old man with a history of alcohol abuse and cirrhosis presents to the emergency department with profuse vomiting. The patient is aggressive, combative, emotionally labile, and has to be chemically restrained. The patient continues to vomit and blood is noted in the vomitus. His temperature is 99.2°F (37.3°C), blood pressure is 139/88 mmHg, pulse is 106/min, respirations are 17/min, and oxygen saturation is 100% on room air. The patient complains of sudden onset chest pain during his physical exam. A crunching and rasping sound is heard while auscultating the heart. Which of the following is the pathophysiology of the most likely diagnosis?

A 5-year-old girl is brought to the physician because of watery discharge from her right eye for 2 weeks. She and her parents, who are refugees from Sudan, arrived in Texas a month ago. Her immunization status is not known. She is at the 25th percentile for weight and the 50th percentile for height. Her temperature is 37.2°C (99°F), pulse is 90/min, and respirations are 18/min. Examination of the right eye shows matting of the eyelashes. Everting the right eyelid shows hyperemia, follicles, and papillae on the upper tarsal conjunctiva. Slit-lamp examination of the right eye shows follicles in the limbic region and the bulbar conjunctiva. There is corneal haziness with neovascularization at the 12 o'clock position. Examination of the left eye is unremarkable. Direct ophthalmoscopy of both eyes shows no abnormalities. Right pre-auricular lymphadenopathy is present. Which of the following is the most likely diagnosis in this patient?

A 64-year-old man presents to the emergency department with sudden onset of chest pain and an episode of vomiting. He also complains of ongoing nausea and heavy sweating (diaphoresis). He denies having experienced such symptoms before and is quite upset. Medical history is significant for hypertension and types 2 diabetes mellitus. He currently smokes and has smoked at least half a pack daily for the last 40 years. Vitals show a blood pressure of 80/50 mm Hg, pulse of 50/min, respirations of 20/min, temperature of 37.2°C (98.9°F), and oximetry is 99% before oxygen by facemask. Except for the patient being visibly distressed and diaphoretic, the examination is unremarkable. ECG findings are shown in the picture. Where is the most likely obstruction in this patient’s cardiac blood supply?

A previously healthy 49-year-old woman comes to the emergency department because of chest pain that radiates to her back. The pain started 45 minutes ago while she was having lunch. Over the past 3 months, she has frequently had the feeling of food, both liquid and solid, getting “stuck” in her chest while she is eating. The patient's vital signs are within normal limits. An ECG shows a normal sinus rhythm with no ST-segment abnormalities. An esophagogram is shown. Further evaluation is most likely to show which of the following?

Q10

A 32-year-old woman patient presents to her family physician with recurrent retrosternal chest pain. She has had similar episodes for the past 7 months along with difficulty swallowing solid as well as liquid food. She recently completed an 8-week course of a proton pump inhibitor, but she is still bothered by the feeling that food gets stuck down her 'food pipe'. Her pain is not related to exertion. She denies any history of acid reflux disease. Her blood pressure is 125/81 mm Hg, respirations are 21/min, pulse is 78/min, and temperature is 36.7°C (98.1°F). She currently does not have pain. A barium swallow X-ray image is normal. Which of the following tests would aid in the diagnosis of this patient's condition?

Red flags in chest pain US Medical PG Practice Questions and MCQs

Question 1: A 36-year-old man presents to the physician with difficulty in breathing for 3 hours. There is no history of chest pain, cough or palpitation. He is a chronic smoker and underwent elective cholecystectomy one month back. There is no history of chronic or recurrent cough, wheezing or breathlessness. His temperature is 38.2°C (100.8°F), pulse is 108/min, blood pressure is 124/80 mm Hg, and respirations are 25/min. His arterial oxygen saturation is 98% in room air as shown by pulse oximetry. After a detailed physical examination, the physician orders a plasma D-dimer level, which was elevated. A contrast-enhanced computed tomography (CT) of the chest shows a filling defect in a segmental pulmonary artery on the left side. Which of the following signs is most likely to have been observed by the physician during the physical examination of this patient’s chest?

A. Pleural friction rub
B. Bilateral wheezing
C. Systolic murmur at the left sternal border
D. Localized rales (Correct Answer)
E. S3 gallop

Explanation: ***Localized rales*** - The patient's presentation with **sudden onset dyspnea**, risk factors (recent surgery, smoking), elevated D-dimer, and a CT scan showing a filling defect in the pulmonary artery strongly points to a **pulmonary embolism (PE)**. - While PE often presents with normal lung auscultation, localized rales or crackles can be heard if there is an associated **pulmonary infarction** or local inflammation. *Pleural friction rub* - A **pleural friction rub** indicates inflammation of the pleura, which can occur in PE if the infarct involves the pleural surface. - However, it is a less common finding than localized rales and is more characteristic of conditions like pleurisy or pneumonia. *Bilateral wheezing* - **Bilateral wheezing** is typically associated with diffuse airway obstruction, as seen in asthma or chronic obstructive pulmonary disease (COPD). - This patient has no history of chronic respiratory conditions and the presentation is acute dyspnea, making diffuse airway obstruction less likely. *Systolic murmur at the left sternal border* - A **systolic murmur at the left sternal border** can be indicative of tricuspid regurgitation, often seen in the setting of **pulmonary hypertension** and right heart strain associated with a massive PE. - However, with a stable blood pressure and moderate heart rate, severe right heart strain leading to a murmur is less likely in this scenario of a segmental PE. *S3 gallop* - An **S3 gallop** is a low-pitched sound heard during early diastole, often indicating **volume overload** or **ventricular dysfunction**. - In the context of PE, an S3 often suggests significant **right ventricular dysfunction** due to acute pressure overload; this is more common with large or massive PEs causing hemodynamic instability, which is not indicated here.

Question 2: A 74-year-old woman is brought by ambulance to the emergency department and presents with a complaint of excruciating chest pain that started about 45 minutes ago. The patient was sitting in the garden when she 1st noticed the pain in the upper abdomen. The pain has persisted and now localizes underneath of the sternum and the left shoulder. Milk of magnesia and aspirin were tried with no relief. The patient had previous episodes of chest pain that were of lesser intensity and rarely lasted more than 10 minutes. She is diabetic and has been managed for hypertension and rheumatoid arthritis in the past. On examination, the patient is breathless and sweating profusely. The vital signs include blood pressure 140/90 mm Hg and heart rate 118/min. The electrocardiogram (ECG) shows Q waves in leads V2 and V3 and raised ST segments in leads V2, V3, V4, and V5. Laboratory studies (including cardiac enzymes at 6 hours after admission show: Hematocrit 45% Troponin T 1.5 ng/mL Troponin I 0.28 ng/mL Creatine kinase (CK)-MB 0.25 ng/mL The patient is admitted and started on analgesia and reperfusion therapy. She shows initial signs of recovery until the 6th day of hospitalization when she starts vomiting and complaining of dizziness. Physical examination findings at this time included heart rate 110/min, temperature 37.7°C (99.9°F), blood pressure 90/60 mm Hg. Jugular venous pressure is 8 cm. A harsh pansystolic murmur is present at the left lower sternal border. ECG shows sinus tachycardia and ST-segment elevation with terminal negative T waves. Laboratory studies show: Hematocrit 38% Troponin T 1.15ng/mL Troponin I 0.18 ng/mL CK-MB 0.10 ng/mL Which of the following best explains the patient's current clinical condition?

A. Aortic dissection complicating myocardial infarction
B. A new myocardial infarction (re-infarction)
C. Acute ventricular septal rupture complicating myocardial infarction (Correct Answer)
D. Acute pericarditis complicating myocardial infarction
E. Cardiac tamponade complicating myocardial infarction

Explanation: ***Acute ventricular septal rupture complicating myocardial infarction*** - The development of a **harsh pansystolic murmur** at the **left lower sternal border** along with signs of **heart failure** (hypotension, tachycardia, increased JVP) approximately a week after a large anterior MI is highly suggestive of **ventricular septal rupture (VSR)**. - The continued ECG changes (ST elevation with terminal negative T waves) and elevated, though improving, cardiac enzymes are consistent with the ongoing myocardial injury and the complications related to it. *Aortic dissection complicating myocardial infarction* - **Aortic dissection** typically presents with **sudden, severe, tearing chest pain** radiating to the back, which is distinct from the patient's initial presentation. - While it can cause hemodynamic instability, it does not typically produce a **pansystolic murmur** at the left lower sternal border. *A new myocardial infarction (re-infarction)* - While the patient is still experiencing symptoms and some ECG changes, the **prominent new pansystolic murmur** and signs of acute heart failure are more indicative of a **mechanical complication** than simply a new MI. - The cardiac enzyme levels, though still elevated, are trending downwards, which would be inconsistent with a large new infarction. *Acute pericarditis complicating myocardial infarction* - **Acute pericarditis** would typically present with **pleuritic chest pain** that improves when leaning forward and a characteristic **pericardial friction rub**. - It would not explain the **pansystolic murmur** or the sudden hemodynamic deterioration to the same extent as VSR. *Cardiac tamponade complicating myocardial infarction* - **Cardiac tamponade** is characterized by **Beck's triad** (hypotension, JVD, muffled heart sounds) and pulsus paradoxus. While the patient has hypotension and JVD, the presence of a **harsh pansystolic murmur** points away from tamponade and towards a structural defect.

Question 3: A 17-year-old girl is admitted to the emergency department with severe retrosternal chest pain. The pain began suddenly after an episode of self-induced vomiting following a large meal. The patient’s parents say that she is very restricted in the foods she eats and induces vomiting frequently after meals. Vital signs are as follows: blood pressure 100/60 mm Hg, heart rate 98/min, respiratory rate 14/min, and temperature 37.9℃ (100.2℉). The patient is pale and in severe distress. Lungs are clear to auscultation. On cardiac examination, a crunching, raspy sound is auscultated over the precordium that is synchronous with the heartbeat. The abdomen is soft and nontender. Which of the following tests would most likely confirm the diagnosis in this patient?

A. Echocardiography
B. Measurement of D-dimer
C. ECG
D. Upper endoscopy
E. Contrast esophagram (Correct Answer)

Explanation: ***Contrast esophagram*** - This patient's history of **self-induced vomiting**, sudden onset of **retrosternal chest pain**, and the presence of a **crunching sound (Hamman's sign)** on precordial auscultation strongly point towards **esophageal rupture (Boerhaave syndrome)**. - A contrast esophagram (using **water-soluble contrast** first) is the most definitive diagnostic test to identify the site and extent of the tear in the esophagus. *Echocardiography* - While an echocardiogram can assess cardiac function and detect pericardial effusions, it is not the primary diagnostic tool for **esophageal rupture**. - It would be more useful if cardiac tamponade or other primary cardiac pathology was suspected. *Measurement of D-dimer* - D-dimer levels are primarily used to evaluate for **thromboembolic events** like pulmonary embolism or deep vein thrombosis. - It would not be helpful in diagnosing an esophageal rupture. *ECG* - An ECG is essential for ruling out **cardiac ischemia** or other acute cardiac events in patients presenting with chest pain. - However, in this clinical scenario, the features are more consistent with esophageal pathology, and an ECG would not confirm esophageal rupture. *Upper endoscopy* - Upper endoscopy can visualize the esophageal mucosa, but it is **contraindicated** in suspected esophageal rupture due to the risk of **perforating the esophagus further** or introducing air into the mediastinum. - It is an invasive procedure that carries significant risks in this emergency.

Question 4: A 55-year-old man presents to the emergency department for chest pain. He states that the pain started last night and has persisted until this morning. He describes the pain as in his chest and radiating into his back between his scapulae. The patient has a past medical history of alcohol abuse and cocaine abuse. He recently returned from vacation on a transatlantic flight. The patient has smoked 1 pack of cigarettes per day for the past 20 years. His temperature is 99.5°F (37.5°C), blood pressure is 167/118 mmHg, pulse is 120/min, and respirations are 22/min. Physical exam reveals tachycardia and clear air movement bilaterally on cardiopulmonary exam. Which of the following is also likely to be found in this patient?

A. Pulmonary artery thrombus
B. Coronary artery thrombus
C. Elevated lipase
D. Asymmetric blood pressures in the upper extremities (Correct Answer)
E. Coronary artery vasospasm

Explanation: ***Asymmetric blood pressures in the upper extremities*** - The patient's presentation with **sudden-onset, severe, tearing chest pain radiating to the back**, combined with **hypertension** and **tachycardia**, is highly suggestive of an **aortic dissection**. Asymmetric blood pressures are a classic sign. - Aortic dissection involves a tear in the intima of the aorta, leading to a false lumen that can compress branch arteries, causing **pulse deficits** or **limb ischemia**, resulting in pressure differences. *Pulmonary artery thrombus* - While a **transatlantic flight** is a risk factor for **pulmonary embolism (PE)**, the described chest pain is typically pleuritic and not usually severe or radiating to the back in this manner. - PE often presents with **dyspnea** and **hypoxia**, which are not prominent features described here. *Coronary artery thrombus* - **Cocaine abuse**, **smoking**, and **hypertension** are risk factors for **myocardial infarction (MI)** due to **coronary artery thrombosis**. However, MI pain is typically crushing or constricting, and radiation to the back between the scapulae is less common than in dissection. - The description of **tearing pain** is more characteristic of aortic dissection than MI. *Elevated lipase* - The patient's history of **alcohol abuse** and **cocaine abuse** are risk factors for **pancreatitis**, which presents with elevated lipase. However, pancreatitis pain is typically **epigastric** and radiates to the back, but it's usually steady, severe, and often associated with nausea/vomiting, not the tearing quality described. - The acute, severe, radiating chest pain pattern is not typical for an initial presentation of pancreatitis. *Coronary artery vasospasm* - **Cocaine abuse** is a known trigger for **coronary artery vasospasm**, leading to angina or MI, and can cause chest pain. - However, the pain from vasospasm is usually anginal in quality, often responsive to nitrates, and less likely to present with the severe, tearing, interscapular back pain and hemodynamic instability suggestive of aortic dissection.

Question 5: A 65-year-old man with hypertension and type 2 diabetes mellitus is brought to the emergency department 20 minutes after the onset of severe anterior chest pain and shortness of breath. He has smoked one pack of cigarettes daily for 30 years. He appears distressed. His pulse is 116/min, respirations are 22/min, and blood pressure is 156/88 mm Hg. Pulse oximetry on room air shows an oxygen saturation of 98%. A grade 3/6, high-pitched, blowing, diastolic murmur is heard over the right upper sternal border. Which of the following is the most likely cause of this patient's symptoms?

A. Rupture of a bulla in the lung
B. Perforation of the esophageal wall
C. Obstruction of the pulmonary arteries
D. Fibrofatty plaque in the aortic wall
E. Tear in the tunica intima (Correct Answer)

Explanation: ***Tear in the tunica intima*** - The sudden onset of **severe anterior chest pain**, hypertension, and a **diastolic murmur** consistent with **aortic insufficiency** points strongly to an **aortic dissection**, which begins with a tear in the tunica intima. - Risk factors like **hypertension**, **smoking**, and **advanced age** increase the likelihood of aortic dissection. *Rupture of a bulla in the lung* - This would typically cause **pneumothorax**, leading to **sharp, pleuritic chest pain** and **dyspnea**, often with diminished breath sounds on the affected side. - A **cardiac murmur** and severe distress in the context of vascular risk factors are not characteristic of a ruptured bulla. *Perforation of the esophageal wall* - Esophageal perforation (Boerhaave syndrome) presents with **severe chest pain**, **vomiting**, and often **subcutaneous emphysema** or **pleural effusion**. - While it causes severe chest pain, the described **diastolic murmur** and absence of vomiting or other specific signs make this less likely. *Obstruction of the pulmonary arteries* - **Pulmonary embolism** (obstruction of pulmonary arteries) typically causes **sudden onset dyspnea**, **pleuritic chest pain**, **tachycardia**, and **hypoxia**, often without a significant cardiac murmur of this nature. - The oxygen saturation of 98% makes a large pulmonary embolism less probable. *Fibrofatty plaque in the aortic wall* - While common in patients with hypertension and smoking history, an **atherosclerotic plaque** in the aortic wall itself rarely causes acute, severe chest pain and a new diastolic murmur unless it leads to an **aortic dissection** or **rupture**. - This option describes a precursor to diseases like aortic dissection but not the acute event itself.

Question 6: A 33-year-old man with a history of alcohol abuse and cirrhosis presents to the emergency department with profuse vomiting. The patient is aggressive, combative, emotionally labile, and has to be chemically restrained. The patient continues to vomit and blood is noted in the vomitus. His temperature is 99.2°F (37.3°C), blood pressure is 139/88 mmHg, pulse is 106/min, respirations are 17/min, and oxygen saturation is 100% on room air. The patient complains of sudden onset chest pain during his physical exam. A crunching and rasping sound is heard while auscultating the heart. Which of the following is the pathophysiology of the most likely diagnosis?

A. Pericardial fluid accumulation
B. Inflammation of the pericardium
C. Dilated and tortuous veins
D. Mucosal tear
E. Transmural tear (Correct Answer)

Explanation: ***Transmural tear*** - The patient's presentation with **profuse vomiting**, followed by **chest pain**, vomiting blood (**hematemesis**), and a **crunching/rasping sound** on cardiac auscultation (**Hamman's sign**), is highly indicative of esophageal rupture or Boerhaave syndrome. - A transmural tear of the esophagus leads to the leakage of gastric contents into the mediastinum, causing **mediastinitis** and potentially **pneumomediastinum**, which produces Hamman's sign. *Pericardial fluid accumulation* - While pericardial fluid accumulation (e.g., in cardiac tamponade) can cause chest pain, it doesn't typically present with **hematemesis** or a history of forceful vomiting. - The classic auscultatory finding for pericardial fluid accumulation is muffled heart sounds, not a crunching sound. *Inflammation of the pericardium* - Pericardial inflammation (**pericarditis**) causes sharp, pleuritic chest pain that often improves with leaning forward, and can be associated with a **pericardial friction rub**. - However, it does not typically cause **hematemesis** or a crunching/rasping sound associated with mediastinal air. *Dilated and tortuous veins* - **Dilated and tortuous veins** (esophageal varices) are common in patients with **cirrhosis** and can lead to profuse hematemesis. - While this patient has cirrhosis and hematemesis, the sudden onset of **chest pain** and the characteristic **Hamman's sign** point away from uncomplicated variceal bleeding and towards esophageal rupture. *Mucosal tear* - A mucosal tear (**Mallory-Weiss tear**) of the esophagus is a common cause of hematemesis after forceful vomiting, especially in alcoholics. - However, it is a **partial-thickness tear** and usually does not cause **chest pain** or **pneumomediastinum** (and thus Hamman's sign), which are hallmark features of a transmural tear.

Question 7: A 5-year-old girl is brought to the physician because of watery discharge from her right eye for 2 weeks. She and her parents, who are refugees from Sudan, arrived in Texas a month ago. Her immunization status is not known. She is at the 25th percentile for weight and the 50th percentile for height. Her temperature is 37.2°C (99°F), pulse is 90/min, and respirations are 18/min. Examination of the right eye shows matting of the eyelashes. Everting the right eyelid shows hyperemia, follicles, and papillae on the upper tarsal conjunctiva. Slit-lamp examination of the right eye shows follicles in the limbic region and the bulbar conjunctiva. There is corneal haziness with neovascularization at the 12 o'clock position. Examination of the left eye is unremarkable. Direct ophthalmoscopy of both eyes shows no abnormalities. Right pre-auricular lymphadenopathy is present. Which of the following is the most likely diagnosis in this patient?

A. Neisserial conjunctivitis
B. Trachoma conjunctivitis (Correct Answer)
C. Acute herpetic conjunctivitis
D. Angular conjunctivitis
E. Acute hemorrhagic conjunctivitis

Explanation: ***Trachoma conjunctivitis*** - The constellation of **follicles and papillae on the upper tarsal conjunctiva**, **limbal follicles**, **corneal haziness with neovascularization (pannus)**, and **pre-auricular lymphadenopathy** in a child from an endemic region (Sudan) is classic for **trachoma**. - This chronic form of conjunctivitis is caused by *Chlamydia trachomatis* serovars A, B, and C, leading to progressive scarring that can eventually cause **trichiasis** and blindness. *Neisserial conjunctivitis* - This condition typically presents with **hyperacute onset**, **copious purulent discharge**, and significant eyelid swelling, often within days of birth or infection. - While it can cause corneal involvement, the chronic follicular and papillary changes with limbal follicles and pannus are not characteristic. *Acute herpetic conjunctivitis* - Usually presents with **unilateral follicular conjunctivitis**, often accompanied by **periorbital vesicles** or a history of cold sores. - While it can cause corneal involvement (typically **dendritic ulcers**), the specific follicular changes, presence of papillae, and chronic course leading to pannus seen here are not typical. *Angular conjunctivitis* - Characterized by **redness, excoriation, and maceration** primarily localized to the **outer canthus** (angle) of the eye, often caused by *Moraxella lacunata* or *Staphylococcus aureus*. - It does not present with the diffuse follicular and papillary changes, limbal follicles, or corneal neovascularization described in this patient. *Acute hemorrhagic conjunctivitis* - This is typically an **acute, highly contagious viral conjunctivitis** characterized by **subconjunctival hemorrhages**, rapid onset, and usually resolves spontaneously. - It does not cause chronic follicular changes, limbal follicles, or corneal neovascularization, and the duration in this patient (2 weeks) suggests a more chronic process.

Question 8: A 64-year-old man presents to the emergency department with sudden onset of chest pain and an episode of vomiting. He also complains of ongoing nausea and heavy sweating (diaphoresis). He denies having experienced such symptoms before and is quite upset. Medical history is significant for hypertension and types 2 diabetes mellitus. He currently smokes and has smoked at least half a pack daily for the last 40 years. Vitals show a blood pressure of 80/50 mm Hg, pulse of 50/min, respirations of 20/min, temperature of 37.2°C (98.9°F), and oximetry is 99% before oxygen by facemask. Except for the patient being visibly distressed and diaphoretic, the examination is unremarkable. ECG findings are shown in the picture. Where is the most likely obstruction in this patient’s cardiac blood supply?

A. Left anterior descending artery
B. There is no obstruction
C. Left circumflex artery
D. Left main coronary artery
E. Right coronary artery (Correct Answer)

Explanation: ***Right coronary artery*** - The ECG shows significant **ST elevation in leads II, III, and aVF**, indicating an **inferior wall myocardial infarction**. This region of the heart is typically supplied by the **right coronary artery (RCA)**. - The patient's presentation with **bradycardia (pulse 50/min)**, **hypotension (BP 80/50 mmHg)**, and **nausea/vomiting** is classic for an inferior MI, often due to RCA occlusion compromising blood supply to the **SA and AV nodes** (which are frequently supplied by the RCA). *Left anterior descending artery* - Obstruction of the **LAD** typically causes **ST elevation in anterior leads (V1-V4)**, which is not seen here. - An LAD occlusion would present as an **anterior MI**, usually without the severe bradycardia and hypotension often seen with inferior MIs caused by RCA occlusion. *There is no obstruction* - The patient's symptoms of **sudden onset chest pain, nausea, diaphoresis**, and particularly the **ECG findings of ST elevation** are highly indicative of an **acute myocardial infarction**, which is caused by coronary artery obstruction. - The severe hemodynamic instability (hypotension, bradycardia) further points towards a significant cardiac event due to occlusion. *Left circumflex artery* - **LCx occlusion** usually leads to **lateral wall MI**, characterized by ST elevation in leads **I, aVL, V5, and V6**, which is not the primary pattern observed in this ECG. - While LCx can sometimes supply the inferior wall, the classic inferior pattern seen here is more commonly associated with RCA occlusion. *Left main coronary artery* - **Left main coronary artery** occlusion is a catastrophic event leading to extensive myocardial ischemia and typically presents with widespread ST depressions or elevation in aVR, reflecting global ischemia and often causing **cardiogenic shock** or **sudden cardiac death**. - The ECG pattern here is localized to the inferior leads, making a left main occlusion an unlikely primary cause.

Question 9: A previously healthy 49-year-old woman comes to the emergency department because of chest pain that radiates to her back. The pain started 45 minutes ago while she was having lunch. Over the past 3 months, she has frequently had the feeling of food, both liquid and solid, getting “stuck” in her chest while she is eating. The patient's vital signs are within normal limits. An ECG shows a normal sinus rhythm with no ST-segment abnormalities. An esophagogram is shown. Further evaluation is most likely to show which of the following?

A. Gastroesophageal junction mass on endoscopy
B. Hypertensive contractions on manometry
C. Elevated lower esophageal sphincter pressure on manometry
D. Multiple mucosal erosions on endoscopy
E. Simultaneous multi-peak contractions on manometry (Correct Answer)

Explanation: ***Simultaneous multi-peak contractions on manometry*** - The history of **dysphagia for both liquids and solids**, chest pain radiating to the back, and the esophagogram showing a **corkscrew esophagus** are highly suggestive of **esophageal spasm**. - **Esophageal manometry** in diffuse esophageal spasm typically reveals simultaneous, high-amplitude, and often multi-peak contractions in the distal esophagus. *Gastroesophageal junction mass on endoscopy* - While dysphagia can be a symptom of a **gastroesophageal junction (GEJ) mass**, the intermittent nature of the dysphagia and the classic "corkscrew" appearance on the esophagogram makes a mass less likely. - A GEJ mass would typically cause **progressive dysphagia**, often more pronounced for solids than liquids over time, and would likely reveal an anatomical obstruction on the esophagogram. *Hypertensive contractions on manometry* - **Hypertensive peristalsis** (nutcracker esophagus) typically presents with abnormally high-amplitude peristaltic contractions, but they remain **coordinated and propagated**, unlike the simultaneous contractions seen in esophageal spasm. - Although chest pain is common in nutcracker esophagus, the hallmark simultaneous contractions for diffuse esophageal spasm are not seen. *Elevated lower esophageal sphincter pressure on manometry* - **Elevated LES pressure** and **incomplete LES relaxation** are characteristic findings in **achalasia**, which also causes dysphagia for both liquids and solids and chest pain. - However, achalasia often presents with a **dilated esophagus** and a **bird's beak appearance** at the GEJ on esophagogram, which is not seen here; instead, the image shows marked tertiary contractions. *Multiple mucosal erosions on endoscopy* - **Mucosal erosions** are typically associated with conditions like **reflux esophagitis** or **pill esophagitis**, which can cause chest pain but often presents with **heartburn** and **odynophagia**. - These conditions do not explain the dysphagia for both liquids and solids or the characteristic "corkscrew" esophagus seen on the imaging.

Question 10: A 32-year-old woman patient presents to her family physician with recurrent retrosternal chest pain. She has had similar episodes for the past 7 months along with difficulty swallowing solid as well as liquid food. She recently completed an 8-week course of a proton pump inhibitor, but she is still bothered by the feeling that food gets stuck down her 'food pipe'. Her pain is not related to exertion. She denies any history of acid reflux disease. Her blood pressure is 125/81 mm Hg, respirations are 21/min, pulse is 78/min, and temperature is 36.7°C (98.1°F). She currently does not have pain. A barium swallow X-ray image is normal. Which of the following tests would aid in the diagnosis of this patient's condition?

A. Electrocardiogram
B. Upper GI endoscopy
C. Manometry (Correct Answer)
D. Injection of botulinum toxin
E. Additional therapy with proton pump inhibitors

Explanation: ***Manometry*** - The patient's symptoms of **recurrent retrosternal chest pain** and **dysphagia for both solids and liquids** suggest a **motility disorder** of the esophagus, such as **achalasia** or **diffuse esophageal spasm**. - **Esophageal manometry** directly measures the pressure and coordination of muscle contractions in the esophagus, identifying abnormalities in peristalsis and sphincter relaxation. *Electrocardiogram* - While chest pain can be cardiac in origin, the patient's symptoms are primarily related to **swallowing** and not exertion, making a primary cardiac cause less likely. - An ECG would be unable to diagnose an **esophageal motility disorder**. *Upper GI endoscopy* - An **upper GI endoscopy** is primarily used to visualize the mucosa of the esophagus, stomach, and duodenum to detect structural abnormalities, inflammation, or ulcers. - It would likely be normal in a pure **motility disorder** and would not provide functional information about esophageal contractions. *Injection of botulinum toxin* - **Botulinum toxin injection** is a treatment option for some esophageal motility disorders (e.g., achalasia), but it is not a diagnostic test. - It works by paralyzing muscles, thereby reducing lower esophageal sphincter pressure. *Additional therapy with proton pump inhibitors* - The patient has already completed an 8-week course of a **PPI** without improvement, and she explicitly denies a history of **acid reflux disease**. - This suggests that her symptoms are unlikely to be acid-related, making further PPI therapy ineffective for diagnosis or treatment.

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