Tbilisi State University, Faculty of Medicine
Course: Case Based Clinical Reasoning
Case: A 57-year old man with chest pain
Student version
Introduction
The patient who describes chest pain represents an immediate challenge! Approximately 60
percent of all chest pain diagnoses are not "organic" in origin, but 40 percent may imply an
imminent catastrophe. Physicians in emergency situations (e.g. in the ER or as a General
Practitioner) must be able to make a proper differential diagnosis of chest pain and adequately
manage a patient with chest pain.
Objective of this CBCR case
After discussing this case, students must have obtained skills for a proper diagnostic approach to
patients with chest pain. They have to know possible causes of chest pain, understand the details
and importance of different ways of presentation of this syndrome and to carry out appropriate
examination, investigation and management.
Preparation
Preparation for this case includes reviewing some topics on internal medicine, emergency
medicine, and critical care medicine referring to: causes of chest pain, associated symptoms,
description of chest pain, risk factors, and management of chest pain. In order to understand this case
better, students have to prepare questions 2 and 3 at home.
Background literature for all students
1. Merck manual of diagnosis and therapy. 2006, p. 65, 355, 580,
2. Harrison’s Principles of Internal Medicine. 17th edition, p 87,
3. Marriot’s Practical Electrocardiology. Ninth edition. Galen. Wagner. p 174.
Additional background literature for peer-teachers:
1. Husser, D. "Evaluation of noncardiac chest pain: diagnostic approach, coping strategies
and quality of life." European journal of pain10.1 (2005): 51-5.
2. Boie, Eric T T."Initial evaluation of chest pain."Emergency medicine clinics of North
America23.4 (2005): 937-57.
3. Lange RA, Hillis LD. Clinical practice. Acute pericarditis. N Engl J Med. 2004;
351(21):2195.
4. Voskuil JH, Cramer MJ, Breumelhof R, Timmer R, Smout AJ. Prevalence of esophageal
disorders in patients with chest pain newly referred to the cardiologist.Chest. 1996; 109 (5):1210.
5. R.M. Bojar. Manual of Perioperative Care in Adult Cardiac Surgery. Wiley-Blackwell. Fifth
edition. 2012. pp. 45-47.
Additional background literature for the consultant, reference for the mini lecture:
1. Meisel J.L, Cotrell D. Differential diagnosis of chest pain in adults. UpToDate 2014. (contents:
differential diagnosis of chest pain in adults)1.
Assessment
Students:
0 points Absence or presence without relevant participation
1 point Normal active participation
Peer teachers:
0 points Poor preparation, insufficient leadership of the session
1 point Sufficient preparation, moderate leadership of the session
2 points Good preparation, good leadership of the session
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Estimated time schedule
Case: 2 hrs (with 15 min break).
Approximate time schedule per question:
Question 1: 5 min
Question 2: 10 min
Question 3: 12 min
Mini Lecture: 10 min
Question 4: 10min
Hand-out 1
Question 5: 10 min
Question 6: 10 min
Hand-out 2
Question 7: 15 min
Hand-out 3
Question 8: 10 min
Question 9: 5 min
Question 10: 5 min
Stage I – Presentation of the patient’s problem
Case
You are a physician at the ER. A 57-year-old man is admitted to the hospital with frontal pain in the
chest wall, over the heart, as he describes. The pain is dull and localized behind the breastbone. It
began acutely, with a feeling of “break up” (tearing) and has lasted for the last 2 days. He says that
during this period he hasn’t felt comfortable and the intensity of the pain increases during inspiration
and with body movement.
Question 1. What is the main problem of the patient?
Question 2. Provide a list of organ systems with their disorders that could be the cause of
chest pain in this particular case, grouped in three categories (I -Likely, II-Less Likely, III –
Not very Likely, but not excluded)
Question 3. Agree upon all relevant hypotheses and discuss the mechanism how they can
cause chest pain.
Question 4. Which questions must be asked to discriminate between the most relevant
hypotheses?
Stage II - Results of history taking
Hand-out 1 (Shown on the screen and read out loud)
Question 5. List the five diagnostic hypotheses that are now most likely, and make a similar
table as in the hand-out, but now for these five specific diseases
Question 6. Which components of the physical examination will you perform?
Stage III - Results of physical examination
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Hand-out 2 (shown on the screen and read out loud)
Question 7. Which next investigations are needed to come to a conclusion?
Stage IV - Results of diagnostic tests
Hand-out 3 (shown on the screen and read out loud)
Question 8. What can be concluded from the results and what final investigation should be
done for the diagnosis?
Question 9. Suggest a treatment and estimate a prognosis.
Question 10. One of the students summarizes the whole case chronologically in a few
minutes
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