Scenario 1 A 65-year-old male presents with retrosternal chest pain described as a
“heavy pressure.” He reports the pain occurs reliably when walking uphill and resolves
within 5 minutes of rest. He has no pain currently. Question: Based on Harrison’s
definitions, how would you classify this clinical presentation? Answer: Stable Angina.
Reference: Harrison’s 22e, Ch. 15, page 102: “Stable angina is characterized by
ischemic episodes that are typically precipitated by a superimposed increase in
oxygen demand during physical exertion and relieved upon resting.” Also Table
15-1: “Precipitated by exertion, cold, or stress; 2–10 min.”
Scenario 2 A 25-year-old female presents with sharp, left-sided chest pain. On
examination, you reproduce the pain by pressing on the costochondral junctions. There is
localized swelling and redness over the area. Question: What is the specific diagnosis
suggested by these findings according to Harrison’s? Answer: Tietze’s syndrome
(Costochondritis).
Reference: Harrison’s 22e, Ch. 15, page 104: “Costochondritis causing tenderness of
the costochondral junctions (Tietze’s syndrome) is relatively common.” And page
107: “Pain arising from the costochondral and chondrosternal articulations may be
associated with localized swelling, redness, or marked localized tenderness.”
Scenario 3 A patient presents with severe chest pain following a bout of violent retching
and vomiting. You suspect esophageal perforation (Boerhaave syndrome). It has been 2
hours since the onset of pain. Question: According to Davidson’s, what specific finding
might you look for on a chest X-ray to support this diagnosis? Answer: Subcutaneous
emphysema, pneumomediastinum, or a pleural effusion.
Reference: Davidson’s 24e, Ch. 9, page 180: “Provided it has been more than 1 hour
since the onset of pain, chest X-ray in oesophageal rupture may reveal subcutaneous
emphysema, pneumomediastinum or a pleural effusion.”
Scenario 4 A patient presents with acute chest pain. The ECG shows ST-segment
elevation, but it is diffuse and involves leads that do not correspond to a specific
coronary anatomic distribution. There is also PR-segment depression. Question:
According to Harrison’s, these ECG findings aid in distinguishing acute MI from which
other condition? Answer: Pericarditis.