CMN 574 Unit 1 Exam Questions with Verified Solutions Graded A+
Common causes of chest pain in the primary care office - Answers Musculoskeletal/ chest wall
pain
Gastrointestinal disorders
Anxiety/psychiatric disorders
Respiratory disorders
Stable angina
Non-ischemic cardiac disorders
Inflammatory disorders/infections
Causes of chest pain seen in Urgent care or ER - Answers Unstable angina/ Acute coronary
syndrome
Pulmonary embolism
Pneumothorax
Esophageal rupture
Aortic dissection
How to manage chest pain - Answers Careful History & Physical Exam
Risk assessment: what factors does this patient have that make a serious cardiac cause more
likely?
Focused testing
Referral to specialist or hospital
Non-cardiac causes of chest pain: Musculoskeletal disorders - Answers Most common non-
cardiac cause of chest pain: almost 40% of patients with CP have a MS disorder/ chest wall pain
Chest wall pain most commonly caused by muscle strain or costochondritis, less common
causes are broken rib, herpes zoster, fibromyalgia, fibrocystic breast, sickle cell crisis, chest
wall contusions, or protracted vomiting
More common in young, active patients involved in sports or work that involves lifting.
MS chest pain - Answers Risk factors: trauma, overuse injury, hx of Chicken pox
Character and location of pain: ranges from sharp to dull, usually more localized and can point
,to area with a finger. Zoster pain described as burning and localized along a dermatone.
Aggravating factors: MS chest wall pain made worse with arm movement or deep inspiration
Duration: gradual onset, longer duration
Exam: chest wall pain often reproducible by palpation of the affected muscles, ligaments or
costochondral junction
Examine for rash associated with zoster, pain may occur before rash develops
Tests: usually none indicated, Xrays if hx of trauma
Treatment: rest, anti-inflammatories, ice/heat
Non-cardiac chest pain: Gastrointestinal disorders - Answers GI disorders account for 20-30% of
patients with chest pain.
Causes include GERD, esophagitis, esophageal spasm, peptic ulcer disease, hiatal hernia, and
gallbladder disease
Factors increasing the likelihood are hx of ulcers, smokers, use of ETOH, and use of NSAIDS or
ASA.
Always ask about OTC pain medication use!
Gastrointestinal disorders - chest pain - Answers Character & Location: GERD be described as
substernal and burning pain, Eosphageal spasm may present as substernal squeezing or
pressure. PUD and pancreatitis may present as epigastric pain radiating to the back.
Timing & duration: usually recurrent, may last minutes to hours.
Aggravating factors: worsened by meals, supine position
Relieved by: antacids, PPI, H2 blockers.
Associated symptoms: nocturnal cough, flatus, belching, dysphagia
Exam findings: pain on palpation of epigastruim
Labs: test for H. pylori, EGD
Treatment: depends on cause: PPIs, antibiotics for H. pylori
Diet, elevate head of bed
Non-cardiac chest pain: Psychogenic causes - Answers Psychogenic causes account for 10-
20% of chest pain
, Causes include stress-related disorders, panic attacks, and somatization
Stress also aggravates other conditions that cause CP such as GERD, asthma, and angina
Psychogenic chest pain - Answers Character & location: varies. Panic disorder: precordial CP,
Depression: constant or intermittent heaviness unrelated to meals or activity
Timing: sudden or gradual
Aggravating factors: stress, hx of panic disorder or depression
Associated symptoms: anxiety, dyspnea/ hyperventilation, tingling/numbness or limbs,
dizziness
Screening: 2 questions highly sensitive for panic disorder
1. "In the past 6 mo, did you ever have a spell or an attack when all of a sudden you felt anxious,
frightened, or very uneasy?"
2. " In the past 6 mo, did you ever has a spell or attack where for no reason your heart suddenly
began to race and you felt faint or couldn't catch you breath?
Yes to either is positive screen, no to both makes panic disorder unlikely.
Non-cardiac chest pain: respiratory disorders - Answers Respiratory disorders account for 5-
10% of chest pain patients
Causes include bronchitis, pneumonia, asthma, COPD, pneumonitis, pleurisy, and pulmonary
embolism
Risk factors for PE: prolonged immobilization, pregnancy, pelvic or lower leg trauma,
hypercoagulability, estrogen use, smoker, and cancer
Respiratory disorders - chest pain - Answers Character & location: varies. Pneumonia dull or no
pain, pleuritic pain (PE, pleuritis) sharp, stabbing, usually localized to one side, worse with deep
breath or cough
Timing: PE: sudden pain, others, more gradual
Aggravating factors: pain with breathing/ coughing
Associated symptoms: fever, cough, wheezing, dyspnea
Exam findings: fever, egophony, rales, wheezes, friction rub, tachycardia
Wells score: predicts risk for PE. Used to determine testing.
Labs: CXR to rule out pneumonia; D-dimer, possible helical CT and venous ultrasound to rule out
Common causes of chest pain in the primary care office - Answers Musculoskeletal/ chest wall
pain
Gastrointestinal disorders
Anxiety/psychiatric disorders
Respiratory disorders
Stable angina
Non-ischemic cardiac disorders
Inflammatory disorders/infections
Causes of chest pain seen in Urgent care or ER - Answers Unstable angina/ Acute coronary
syndrome
Pulmonary embolism
Pneumothorax
Esophageal rupture
Aortic dissection
How to manage chest pain - Answers Careful History & Physical Exam
Risk assessment: what factors does this patient have that make a serious cardiac cause more
likely?
Focused testing
Referral to specialist or hospital
Non-cardiac causes of chest pain: Musculoskeletal disorders - Answers Most common non-
cardiac cause of chest pain: almost 40% of patients with CP have a MS disorder/ chest wall pain
Chest wall pain most commonly caused by muscle strain or costochondritis, less common
causes are broken rib, herpes zoster, fibromyalgia, fibrocystic breast, sickle cell crisis, chest
wall contusions, or protracted vomiting
More common in young, active patients involved in sports or work that involves lifting.
MS chest pain - Answers Risk factors: trauma, overuse injury, hx of Chicken pox
Character and location of pain: ranges from sharp to dull, usually more localized and can point
,to area with a finger. Zoster pain described as burning and localized along a dermatone.
Aggravating factors: MS chest wall pain made worse with arm movement or deep inspiration
Duration: gradual onset, longer duration
Exam: chest wall pain often reproducible by palpation of the affected muscles, ligaments or
costochondral junction
Examine for rash associated with zoster, pain may occur before rash develops
Tests: usually none indicated, Xrays if hx of trauma
Treatment: rest, anti-inflammatories, ice/heat
Non-cardiac chest pain: Gastrointestinal disorders - Answers GI disorders account for 20-30% of
patients with chest pain.
Causes include GERD, esophagitis, esophageal spasm, peptic ulcer disease, hiatal hernia, and
gallbladder disease
Factors increasing the likelihood are hx of ulcers, smokers, use of ETOH, and use of NSAIDS or
ASA.
Always ask about OTC pain medication use!
Gastrointestinal disorders - chest pain - Answers Character & Location: GERD be described as
substernal and burning pain, Eosphageal spasm may present as substernal squeezing or
pressure. PUD and pancreatitis may present as epigastric pain radiating to the back.
Timing & duration: usually recurrent, may last minutes to hours.
Aggravating factors: worsened by meals, supine position
Relieved by: antacids, PPI, H2 blockers.
Associated symptoms: nocturnal cough, flatus, belching, dysphagia
Exam findings: pain on palpation of epigastruim
Labs: test for H. pylori, EGD
Treatment: depends on cause: PPIs, antibiotics for H. pylori
Diet, elevate head of bed
Non-cardiac chest pain: Psychogenic causes - Answers Psychogenic causes account for 10-
20% of chest pain
, Causes include stress-related disorders, panic attacks, and somatization
Stress also aggravates other conditions that cause CP such as GERD, asthma, and angina
Psychogenic chest pain - Answers Character & location: varies. Panic disorder: precordial CP,
Depression: constant or intermittent heaviness unrelated to meals or activity
Timing: sudden or gradual
Aggravating factors: stress, hx of panic disorder or depression
Associated symptoms: anxiety, dyspnea/ hyperventilation, tingling/numbness or limbs,
dizziness
Screening: 2 questions highly sensitive for panic disorder
1. "In the past 6 mo, did you ever have a spell or an attack when all of a sudden you felt anxious,
frightened, or very uneasy?"
2. " In the past 6 mo, did you ever has a spell or attack where for no reason your heart suddenly
began to race and you felt faint or couldn't catch you breath?
Yes to either is positive screen, no to both makes panic disorder unlikely.
Non-cardiac chest pain: respiratory disorders - Answers Respiratory disorders account for 5-
10% of chest pain patients
Causes include bronchitis, pneumonia, asthma, COPD, pneumonitis, pleurisy, and pulmonary
embolism
Risk factors for PE: prolonged immobilization, pregnancy, pelvic or lower leg trauma,
hypercoagulability, estrogen use, smoker, and cancer
Respiratory disorders - chest pain - Answers Character & location: varies. Pneumonia dull or no
pain, pleuritic pain (PE, pleuritis) sharp, stabbing, usually localized to one side, worse with deep
breath or cough
Timing: PE: sudden pain, others, more gradual
Aggravating factors: pain with breathing/ coughing
Associated symptoms: fever, cough, wheezing, dyspnea
Exam findings: fever, egophony, rales, wheezes, friction rub, tachycardia
Wells score: predicts risk for PE. Used to determine testing.
Labs: CXR to rule out pneumonia; D-dimer, possible helical CT and venous ultrasound to rule out
