chest pain case 3

Chest pain Case 3

A 35-year-old man with no significant past medical history presents to clinic with a six week history of worsening chest discomfort and pain.
He describes the pain as a substernal burning sensation that occasionally wakes him up at night and is often worse after he eats. He
sometimes notices a sour taste in his mouth when he wakes up in the morning. He has no dysphagia or odynophagia. The pain is unrelated
to exertion, and he jogs 3 miles every other day without difficulty or chest pain. His vital signs and physical examination are normaI.


Question 1 of 6
Which of the following is the most likely diagnosis?
/ A. Acute viral pericarditis
/ B. Aortic dissection
/ C. Candida esophagitis
/ D. Gastroesophageal reflux disease (GERD)
/ E. Stable angina


Question 2 of 6
Which of the following tests would be most likely to confirm the probable diagnosis?
/ A. 24-hour ambulatory esophageal luminal pH monitoring
/ B. Cardiac angiogram
/ C. Chest radiograph
/ D. Exercise treadmill test
/ E. Serologic blood tests for H. Pylori infection



Question 3 of 6
The patient is treated with cimetidine, which completely relieves his symptoms. Which of the following is the mechanism of action of this
medication?
/ A. Beta-1 adrenergic blockade
/ B. Histamine H2 receptor blockade
/ C. Inhibition of cell wall synthesis
/ D. Inhibition of cyclooxygenase
/ E. Smooth muscle relaxation


Question 4 of 6
The physician cautions the patient about cimetidine because of which of the following potential side effects?
/ A. CNS depression
/ B. Hypertensive crisis
/ C. Inhibition of hepatic metabolism
/ D. Masking symptoms of hypoglycemia
/ E. Ototoxicity


Question 5 of 6
The patient's symptoms are initially controlled on cimetidine. After 10 years, he develops refractory symptoms, and the physician places him
on a proton pump inhibitor. Which of the following medications was most likely prescribed?
/ A. Lansoprazole
/ B. Loperamide
/ C. Metoclopramide
/ D. Ondansetron
/ E. Ranitidine


Question 6 of 6
Histologic examination of the affected tissue shows Barrett's esophagus. This is most correctly described as which of the following?
/ A. Adenocarcinoma
/ B. Esophageal stricture
/ C. H.Pylori infection
/ D. Localized outpouching of the esophageal wall
/ E. Metaplasia of the squamous epithelium

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Chest pain Case 3 answers


Q1
The correct answer is D. A patient who presents with chest discomfort that is burning in nature, and worsened after eating without symptoms of dysphagia or odynophagia, most likely has gastroesophageal reflux disease (GERD). GERD occurs when there is reflux of gastric contents into the esophagus. This may occur with or without inflammation. It is often caused by inappropriate relaxation of the lower esophageal sphincter. Certain foods such as peppermint, caffeine, and high-fat and spicy foods are often associated with GERD.
Acute viral pericarditis (choice A) would present with more severe and sudden onset of chest pain that is relieved with leaning forward or sitting up. Acute viral pericarditis is often associated with a prodrome and usually presents with a fever. Occasionally, a pericardial friction rub can be heard on exam.
Aortic dissection (choice B) would also present as sudden onset of severe chest pain, which often radiates to the back. Patients can have hypotension, depending on the severity of the dissection. Patients can also have unequal pulses in their extremities if the dissection affects one of the major arteries branching off the aortic arch.
Candida esophagitis (choice C) would present with dysphagia and odynophagia. Patients also have oral thrush, and generally are immunocompromised. These patients usually have a fever.
Stable angina (choice E) should present with typical chest pain that is worsened after exertion. The fact that this patient can jog 3 miles without difficulty goes against stable angina. Furthermore, he is young and does not have any risk factors for cardiac disease such as hypertension, diabetes, or hypercholesterolemia.


Q2
The correct answer is A. Twenty-four hour ambulatory esophageal luminal pH monitoring is one of the most sensitive tests for GERD. In most cases, the disease is diagnosed clinically by history, but pH monitoring would help confirm the diagnosis.
Cardiac angiograms (choice B) are used to evaluate the coronary arteries for signs of blockage, to evaluate heart function, or to evaluate cardiac valve function.
A chest radiograph (choice C) can be used to evaluate the structures in the thorax, but will not help confirm the diagnosis because GERD patients generally have normal chest radiographs.
An exercise treadmill test (choice D) is used to evaluate patients who are believed to have underlying coronary heart disease or to rule out heart disease.
Serologic blood testing for H. pylori infection (choice E) only documents the presence of a current infection or the history of an H. pylori infection. A past or present infection does not confirm a diagnosis, because GERD can occur in the setting with or without H. pylori. Furthermore, the role of H. pylori in GERD is still unclear.


Q3
The correct answer is B. Cimetidine and other histamine H2 receptor blockers such as ranitidine block the action of histamine on H2 receptors, resulting in a decrease in gastric acid production, thus decreasing the symptoms of GERD.
Beta-1 adrenergic blockade (choice A) (e.g., atenolol, metoprolol) is used to lower blood pressure, which is not related to GERD.
Inhibition of cell wall synthesis (choice C) (e.g., amoxicillin) is a mechanism that is used by many antibiotics. GERD can be associated with the presence of H. pylori, but the treatment of H. pylori with antibiotics in GERD patients remains controversial, and its benefit remains questionable.
Inhibition of cyclooxygenase (choice D) (e.g., ibuprofen, naproxen) does not play a role in the treatment of GERD. GERD may or may not be associated with inflammation of the esophagus, but anti-inflammatory agents may actually worsen symptoms.
Smooth muscle relaxation (choice E) (e.g., nitroglycerin) does play a role in the relief of esophageal spasm, but this patient does not complain of dysphagia or odynophagia.


Q4
The correct answer is C. Many drugs can lead to clinically significant drug interactions via inhibition of the hepatic drug-metabolizing enzymes, particularly the cytochrome P450 isozymes. This can lead to unwanted elevations of plasma drug levels. Cimetidine is a classic example of one of these drugs. Other examples include erythromycin, ketoconazole, sulfonamides, quinidine, and disulfiram.
Benzodiazepines and barbiturates are examples of drugs that can cause CNS depression (choice A).
MAO inhibitors prior to the ingestion of tyramine-containing foods can cause a hypertensive crisis (choice B).
Beta blockers can mask the symptoms of hypoglycemia (choice D).
Aminoglycosides can produce ototoxicity (choice E). The risk of ototoxicity may be further increased if the patient is also taking loop diuretics.


Q5
The correct answer is A. Lansoprazole is a proton pump inhibitor and acts directly to inhibit the gastric parietal cell hydrogen-potassium ATPase. It can be used as the initial treatment for GERD, or for refractory cases.
Loperamide (choice B) is an anti-diarrheal agent, which inhibits peristalsis. Using it in this setting may worsen the symptoms of GERD.
Metoclopramide (choice C) stimulates upper gastrointestinal motility. It can be used in refractory cases of GERD, but it is not a proton pump inhibitor.
Ondansetron (choice D) is an antiemetic and acts by selectively antagonizing serotonin 5-HT3 receptors. It is primarily used is severe cases of nausea, such as in patients receiving chemotherapy for cancer treatment.
Ranitidine (choice E) is also an histamine H2 receptor blocker, like cimetidine. Some patients who do not respond to one histamine H2 receptor blocker, may respond to another, but ranitidine blocks the action of histamine on H2 receptors, resulting in a decrease in gastric acid production. It is not a proton pump inhibitor.


Q6
The correct answer is E. Patients who have long-standing GERD are at risk for development of Barrett's esophagus, which is the replacement of the normal esophageal squamous epithelium with columnar epithelium (metaplasia). This is a premalignant lesion that needs to be monitored regularly for the development of adenocarcinoma.
Adenocarcinoma (choice A) is a malignant lesion that can result from cellular metaplasia, but Barrett's esophagus is the premalignant lesion that occurs before the development of adenocarcinoma of the esophagus.
Esophageal strictures (choice B) can occur in patients with long-standing GERD, but the presence of a stricture does not mean that there is cellular dysplasia, or Barrett's esophagus.
H. pylori infection (choice C) can occur in the setting of GERD, but it is not synonymous with Barrett's esophagus.
An esophageal diverticulum is a localized outpouching of the esophageal wall (choice D). This is unrelated to Barrett's esophagus.