13. Chest Pain

Question 1

Name chest pain DDX : Cardiac (3)

Answer 1

• Acute Coronary Syndrome (ACS)
• Myocarditis
• Pericarditis

Question 2

Describe : Pericarditis (3)

Answer 2

• Pleuritic chest pain, decreased on leaning forward
• Diffuse ST elevation, PR depression, pericardial friction rub
• Treatment : Supportive, NSAIDs, steroids

Question 3

Name chest pain DDX : Pulmonary (5)

Answer 3

• Pulmonary Embolism
• Tension pneumothorax
• Pneumonia
• COPDE
• Acute chest syndrome (sickle cell)

Question 4

Describe : Thoracic aortic dissection (4)

Answer 4

• Sudden
• Severe pain radiating to back
• Widened mediastinum on CXR,
• > 20mmHg difference in BP on left vs. right

Question 5

Describe tx : Thoracic aortic dissection (2)

Answer 5

• Decrease contractility and BP (target sBP <120)
• ABC, surgery/ICU

Question 6

Name chest pain DDX : GI (5)

Answer 6

• Boerhaave’s sydrome (esophageal rupture)
• GERD/Peptic ulcer disease

Question 7

Describe tx : Boerhaave’s sydrome (esophageal rupture) (4)

Answer 7

• NPO
• IV Abx
• IV PPI
• Endoscopy/surgical repair

Question 8

Name chest pain DDX : Chest wall (3)

Answer 8

• Costochondritis
• MSK
• Herpes Zoster

Question 9

Name chest pain DDX : Psychogenic (1)

Answer 9

Anxiety

Question 10

For chest pain, refer to emergency if (time) for monitoring of worsening symptoms and potential complications

Answer 10

<24h

Question 11

Name score to help prediction rule to aid in out-patient primary care decision-making (1)

Answer 11

Marburg Heart Score (MHS)

Question 12

May consider investigations (EKG +/- STAT Troponin) in office-setting in only certain cases. Name them. (2)

Answer 12

• Resolved symptoms with ACS symptoms >24h prior to presentation
• Atypical chest pain with very low likelihood of ACS (and want to “rule out” ACS), consider repeat 3h after presentation if symptoms <6h

Question 12

Describe : Marburg Heart Score (MHS)

Answer 12

Assign one point for each of the following
* Age/sex: men 55 years or older, women 65 years or older
* Known clinical vascular disease (CAD, occlusive vascular disease, cerebrovascular disease)
* Pain worse with exercise
* Pain not elicited with palpation
* Patient assumes pain is of cardiac origin

0-1 points predicts a 1% CAD risk
0-2 points predicts a 3% CAD risk

Question 13

Nommez éléments du WELLS (7)

Answer 13

• Signes et sx clinique TVP (+3)
• PE est le dx n°1 ou tout aussi probable (+3)
• fréquence cardiaque > 100 (+1.5)
• Immobilisation au moins 3 jours ou intervention chirurgicale au cours des 4 semaines précédentes (+1.5)
• EP ou TVP antérieurs objectivement diagnostiqués (+1.5)
• Hémoptysie (+1)
• Malinité avec traitement dans les 6 mois ou palliatif (+1)

Question 14

Comment interpréter score WELLS?

Answer 14

< 2 = prob prêtes environ 3.4%
< 4.5 peu prob
> 4.5 prob

Question 15

When to use PERC rule ?

Answer 15

Rules out PE if no criteria are present and pre-test probability is < or = 15%

Question 16

Nommez composante PERC rule (8)

Answer 16

• Age > ou = 50
• HR> ou = 100
• SatO2 < 95%
• Unilateral leg swelling
• Hemoptysis
• Chx récente ou trauma (Surgery or trauma < or = 4 weeks ago requiring tx with general anesthesia)
• Prior EP ou TVP
• Hormone use (OCP, hormone replacement or estrogenic hormones use in males or female patients)