A. Myocardial infarction – Explanation
This is clear that this is a myocardial infarction. Atypical presentations of myocardial infarction are
common. They may present with abdominal pain like in the question above. Atypical symptoms incude
abdominal discomfort or jaw pain. The remaining symptoms are quite characteristic of myocardial
infarction
- In pericarditis, the pain is aggravated by inspiration or lying flat and relieved by leaning forward.
Pericardial rub may present and there may be fever - In pulmonary embolism, patients would present with dyspnoea and pleuritic chest pain. The
writers of the exam would also give other hints like having a history of immobilisation or a long
travel - In costochondritis, the pain is localized at the costochondral junction which is enhanced by
motion, coughing, or sneezing. The writers would usually give a history of repeated minor chest
injury or activities that one is unused to – perhaps decorating or moving furniture. - In pneumothorax, the pain is not central but pleuritic and there are no signs that indicated that this
is pneumothorax in the given question
The given picture of central chest pain for 45 minutes (more than 30 minutes), sweating and dyspnoea
with major risk factor of diabetes mellitus and hypertension suggest the diagnosis of myocardial infarction
ACUTE MYOCARDIAL INFARCTION PRESENTATION
Chest pain (central chest pain may not be the main symptom):
-
- Three quarters of patients present with characteristic central or epigastric chest pain radiating to
the arms, shoulders, neck or jaw - The pain is described as substernal pressure, squeezing, aching, burning or even sharp pain
Radiation to the left arm or neck is common - Chest pain may be associated with sweating, nausea, vomiting, dyspnoea, fatigue and/or
palpitations
- Three quarters of patients present with characteristic central or epigastric chest pain radiating to
Shortness of breath
Atypical presentations are common and tend to be seen in women, older men, and people with diabetes.
Atypical symptoms include abdominal discomfort or jaw pain. Elderly patietns may even present with
altered mental state
ACUTE CHEST PAIN DIFFERENTIALS
| Condition | Signs and Symptoms |
| Ischaemic cardiac pain | Retrosternal “pressure”, tightness, “constricting”; radiates to shoulders, arms, neck, or jaw; associated with diaphoresis, sweating, nausea, pallor |
| Pericarditis | Atypical, retrosternal pain; sometimes pleuritic; positional (relieved on sitting forward) |
| Gastroesophageal reflux disease | Retrosternal “burning”; associated with indigestion; pain when supine, after food, alcohol, or NSAIDs; relieved by antacids |
| Aortic dissection | “Tearing” pain, sudden onset; radiates to back; diaphoresis, hypotensive, tachycardic; difference in blood pressures/pulses; abnormal or absent peripheral pulses; new murmur (aortic regurgitation) |
| Pulmonary embolism | Acute respiratory distress; diaphoresis, hypotensive, tachycardic, hypoxemia; pleural rub |
| Pneumothorax | Pleuritic, sharp, positional, sudden onset; associated with abrupt breathlessness; diminished breath sounds, hyperresonance to percussion |
| Pneumonia | Associated with cough, sputum, and fever |
| Musculoskeletal | Sharp, positional, pleuritic; aggravated by movement such as deep inspiration, coughing, twisting of neck, or thoracic cage |
