Chapter 86: Chest Pain (Noncardiac) Buttaro: Primary Care: A Collaborative Practice, 6th Edition

Multiple Choice

1. A patient presents to an emergency department reporting chest pain. The patient describes the pain as being sharp and stabbing and reports that it has been present for several weeks. Upon questioning, the examiner determines that the pain is worse after eating. The patient reports getting relief after taking a friend’s nitroglycerin during one episode. What is the most likely cause of this chest pain?

a. Aortic dissection pain b. Cardiac pain c. Esophageal pain d. Pleural pain

ANS: C a. Wean patient from proton pump inhibitor (PPI).

Pain that is constant for weeks or is sharp and stabbing is not likely to be cardiac in origin. Both esophageal and cardiac causes will be attenuated with sublingual nitroglycerin. Aortic dissection will cause an abrupt onset with the greatest intensity at the beginning of the pain. Pleural pain is usually related to deep breathing or cough.

2. When a patient reports experiencing chronic chest pain that occurs after meals, the provider suspects gastroesophageal reflux disease (GERD) and prescribes a proton pump inhibitor. After 2 months the patient reports improvement in symptoms. What is the next action in treating this patient?

NURSINGTB.COM b. Order esophageal pH monitoring. c. Refer the patient to a gastroenterologist. d. Schedule an upper endoscopy.

ANS: A a. Order a chest radiograph. b. Prescribe an antibiotic. c. Recommend an NSAID. d. Refer to a cardiologist.

Often the effectiveness of treatment with a PPI is diagnostic and is equal to or better than more invasive and expensive testing. If the patient continues to show improvement, the patient is weaned off of the PPI. Most patients do well and there is no need to order tests or refer for evaluation. If patients do not do well, further testing is needed.

3. A high school athlete reports recent onset of chest pain that is aggravated by deep breathing and lifting. A 12-lead electrocardiogram in the clinic is normal. The examiner notes localized pain near the sternum that increases with pressure. What will the provider do next?

ANS: C

This patient has symptoms consistent with chest wall pain because chest pain occurs with specific movement and is easily localized. Since the ECG is normal, there is no need to refer to a cardiologist. The patient does not have symptoms of pneumonia, so a radiograph or antibiotic is not needed. NSAIDs are recommended for comfort.