ABIM / Internal Medicine Board Review Question: Cardiology
Happy Friday! It’s been a while since we’ve put up a internal medicine board review question. This one is straight out of the Internal Medicine QBank!
21-year-old female presents to the ED for pain in her chest with deep breaths. She denies any fevers or chills at this time but admits that she just recovered from a cold a week ago. She denies cough, night sweats, weight loss or any other symptoms. The patient doesn’t report any medical problems at this time. She denies smoking or doing illegal drugs but drinks alcohol socially. Family history is non-contributory. She denies using any medications including oral contraceptives. Physical exam indicates normal vital signs but show decreased capacity to take deep breaths because of pain. Lungs are clear. EKG is normal sinus rhythm. Which of the following should be done next for the patient?
A. D-dimer blood test
B. Chest xray
C. Cardiac enzymes
D. Administer NSAIDs
E. Admit for observation and perform a cardiac stress test
The answer below….
Patient’s recent history of an upper respiratory infection and complaint of pleuritic chest pain now is suggestive of pleurisy. Choice D (NSAIDs) are the mainstay of treatment.
Pleurisy is defined as inflammation of the pleural membrane surrounding the lung, leading to a sensation of chest pain (usually sharp in character) when inhaling deeply or coughing. Pleurisy may result from conditions such as:
● Infections (such as an upper respiratory infection)
● Asbestos exposure
● Trauma to the chest
● Rheumatoid arthritis
The primary symptom of pleurisy is chest pain. Deep breathing, coughing, and chest movement can all exacerbate the pain. Dyspnea or tachypnea may also be noted. Diagnosis for pleurisy is clinical after ruling out other diagnoses for which the patient is at high risk. A D-dimer blood test could be ordered if pulmonary embolism was suspected. This patient has normal vital signs including a normal heart rate. The patient doesn’t take oral contraceptives (OCPs) which is a risk factor for developing pulmonary embolism (PE). Since she is not on oral contraceptives (OCPs) or have other risk factors for a PE, Choice A (D-dimer) does not need to be checked.
EKG was normal so we don’t need to check cardiac enzymes or admit for observation.
While in clinical practice, Choice B (Chest xray) would likely already have been checked at this point in the vignette, we are able to treat without having to order the chest xray. Note that the patient’s lungs are clear on exam.
The history gives the best clue that she has pleurisy. NSAIDs are the primary treatment here. If another cause had also been present, such as a pneumonia, she would need additional treatment.