Master the board step 3

Master the Boards: USMLE Step 3
The most common cause of chest pain that is not cardiac in etiology is a gastrointestinal
(acid reflux) problem.
a. A patient comes to the emergency department with chest pain. The pain also
occurs in the epigastric area and is associated with a sore throat, a bad metallic
taste in the mouth, and a cough. What do you recommend?
b. An alcoholic patient comes to the emergency department with chest pain. There
is nausea and vomiting and epigastric tenderness. What do you recommend?
c. A patient comes to the emergency department with chest pain. There is rightupper
quadrant tenderness and mild fever. What do you recommend?
Answers:
a. Give a proton pump inhibitor.
b. Check amylase and lipase levels.
c. Order an abdominal sonogram for gallstones.
Besides chest pain, other clues to ischemic disease as the cause of chest pain
are as follows:
··
Dull pain
··
Lasts 15–30 minutes
··
Occurs on exertion
··
Substernal location
··
Radiates to the jaw or left arm
Physical Findings
There is nothing unique or pathognomonic about the physical findings of
ischemic heart disease. Physical findings such as tenderness only tell you the
patient does not have ischemic disease. There is no buzzword for physical
examination of CAD that indicates, “Aha! This is coronary disease.” However,
for CCS, it is critical to know what could be abnormal so you know which
pieces of the physical to choose.
Piece of Physical Exam
Cardiovascular (CV)
Chest
General exam
Extremities
Findings That Could Be Abnormal
S3 gallop: Dilated left ventricle
S4 gallop: Left ventricular hypertrophy
Jugulovenous distention
Holosystolic murmur of mitral regurgitation
Rales suggestive of congestive heart failure
Distressed patient, short of breath, clutching chest
Edema
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