MKSAP: 60-year-old woman with substernal chest pain

Test your medicine knowledge with the MKSAP challenge, in partnership with the American College of Physicians. A 60-year-old woman is evaluated for a 3-week history of substernal chest pain. The pain is dull, nonradiating, and unrelated to activities. Sometimes the pain is worse after eating spicy foods and can be occasionally triggered by emotional stress. She has not had shortness of breath or weakness. She is moderately active, walking a mile each day. She generally eats a “healthy heart” diet but has never had her lipid levels evaluated. She has never smoked cigarettes. There is no family history of heart disease. Other than the current problem, she is well and takes no medications. On physical examination, blood pressure is 135/75 mm Hg, pulse rate is 70/min, and respiration rate is 12/min. The remainder of the examination is normal. An electrocardiogram is normal. Which of the following is the appropriate next step in management? A. Ambulatory pH testing B. Esophageal manometry C. Exercise stress test D. Upper endoscopy MKSAP Answer and Critique The correct answer is C. Exercise stress test. The most appropriate next step in management is an exercise stress test. Chest pain caused by esophageal disorders can be difficult to distinguish from cardiac chest pain because of the anatomic proximity and common innervation of the esophagus and the heart. Esophageal chest pain is often prolonged, nonexertional, and associated with other esophageal symptoms such as dysphagi...
Source: Kevin, M.D. - Medical Weblog - Category: General Medicine Authors: Tags: Conditions Heart Source Type: blogs