Acute Medicine - Chest pain

Question 1

3 ddx in older adults that are dangerous?

Answer 1

MI, dissecting aortic aneurysm, PE

Question 2

possible areas of radiation in pain for AMI

Answer 2

back
neck
jaw
left arm

Question 3

difference between angina and AMI

Answer 3

angina pain is reversible by GTN, rest while AMI is not

Question 4

GI condition that can be confused with angina

Answer 4

oesophageal spasm

Question 5

Mr TB, aged 45, labourer
2 weeks retrosternal discomfort radiating to throat & jaw. Precipitated by exercise or after a heavy meal. Relieved within a few minutes by rest
O/E: NAD

Answer 5

Angina

Question 6

Mrs WA, aged 60, musician
Severe ‘crushing’ retrosternal pain of 45 minutes duration, vomiting, sweating and anxiety.
O/E: pale, clammy, dyspnoea, restless and apprehensive. Pulse and BP normal.

Answer 6

AMI

Question 7

Mr LN, aged 65, surgeon
Sudden onset, severe ‘tearing’ retrosternal and interscapular pain. Radiates to abdomen. Sweating and anxiety
O/E: unequal pulses (between carotid and femoral)
BP 200/115

Answer 7

dissecting aortic aneurysm

Question 8

Mrs JH aged 54, nurse
Sudden onset dreary dull retrosternal pain and dyspnoea. Associated “blackout”, sweating, agitation.
O/E: R 25/min, P 190/min
BP 90/60

Answer 8

PE

Question 9

Mr WZ aged 49, farmer

Gradual onset (over hours) of pleuritic chest pain aggravated by coughing and deep inspiration. Preceding flu like illness. Fever, malaise.
O/E: R 22min, P 95/min,
BP 90/65
Friction rub over heart

Answer 9

viral pericarditis

Question 10

Mr WP aged 23 soldier
Sudden onset right sided. Moderate chest pain while riding bicycle.
Pleuritic type sharp stabbing pain. Associated dyspnoea. PH: Asthma
O/E: R 28, P 92, BP 110/80
Chest: hyper-resonant to percussion, decreased breath sounds.

Answer 10

Pneumothorax

Question 11

Mr GS aged 59, salesman
Recurrent episodes of epigastric and retrosternal burning pain radiating to neck and sometimes to back. Pain aggravated by bending over and after retiring to bed. Precipitated by heavy meals and wine

Answer 11

GORD

Question 12

Mr LH aged 55, hairdresser
Recurrent episodes of pain in back of chest with radiation around chest wall. Aggravated by deep breathing and exertion. Pain is dull and aching
O/E: tenderness over T5 & T6 vertebrae

Answer 12

spinal dysfunction

Question 13

Mrs SB aged 41, flight attendant
Recurrent episodes of left side precordial and submammary discomfort. Usually a dull pain with stabbing episodes.
O/E: NAD

Answer 13

costochondritis

Question 14

3 days very sharp severe pain which goes around the chest wall on right side. The pain does not cross the midline. Not pleuritic in nature.
O/E: NAD

Answer 14

shingles

Question 15

what is the acute management of asthma?

Answer 15

DRABC
Murtagh’s rule: O2, IV, measure vital signs
salbutamol 5mg nebulized continuous and ipratropium 500mcg nebulized (once)
hydrocortisone IV 100 - 250mg
further investigation CXR for pneumothorax
if not progressing –> consider IV salbutamol, consider IV adrenaline 0.5mg IM if not progressing

Question 16

what is the acute management of hypoglycemia

Answer 16

DRABC
O2, IV, Measure and monitor vitals
if severe: give 50% dextrose (50mg) IV or glucagon 1mg IM

Question 17

what is the acute management of MI

Answer 17

DRABC 
O2, IV, measure and monitor vitals
(MONASH)
morphine - 2.5 - 5mg IV and metoclopramide 10m IV (PRN)
O2 100% 
GTN sub lingual 
Aspirin 300mg 
Streptokinase/thrombolyse if less than 90min away from hospital 
Heparin IV

Question 18

acute airway obstruction

Answer 18

DRABC
assess severity of upper airway obstruction
if partial obstruction, encourage coughing
if full obstruction, 5X back thrust, 5X sharp chest press
if unconscious, empty throat with finger sweep, start CPR

Question 19

acute intoxication/narcotic overdose

Answer 19

DRABC
(first line) naloxone 0.4g IM
followed by naloxone 0.2 - 0.4 mg IV, PRN

Question 20

what is the treatment of acute anaphylaxis

Answer 20

DRABC
position legs supine
IV adrenaline: 0.3 - 0.5 mg IM (adult) to lateral thigh and repeat every 3 - 5 minute
10mcg/kg IM (child) to lateral thigh and repeat every 3 - 5 minute
give IV N. Saline
if patient is experiencing:
stridor = adrenaline 5mg/5ml nebulized
bronchospasm = salbutamol 5mg neb and 250mg hydrocortisone

Question 21

what is the role of antihistamines in anaphylaxis?

Answer 21

there is no role

Question 22

what is the tx of a snake bite?

Answer 22

DRABC
murtagh’s law: IV, O2, Monitor vitals
assess for signs of envenomation such as: coagulopathy, neurotoxic muscle paralysis, muscle damage causing renal failure
treat wound
if significant envenomation –> refer and start IV anti venom

Question 23

what is the tx of the status epilepticus

Answer 23

DRABC, send for help
murtagh’s law; o2, iv, mm vital signs
support c-spine
give immediate benzodiazepine IV - 0,2mg/kg IV diazepam, midazolam 0.1mg/kg IV
if unresponsive, give 15mg/kg IV over 30 minutes w/ a loading dose

Question 24

what is the tx of severe migraine

Answer 24

DRABC
murtagh’s law: O2, IV, MM vital signs
IV normal saline 500ml stat followed by N saline 500 - 1000ml over next 1 - 2h
give chlorpromazine 12.5mg IV for anti emetic

Question 25

what is the tx of potential meningococcal septicemia

Answer 25

DRABC
murtagh’s law: o2, iv, mm vital signs
dexamethasone 10mg OR hydrocortisone 200mg IV before antibiotics
benpen I.V 60mg/kg or IM up to 2.4g max
ceftriaxone 100mg/kg IV or IM up to 4.0g max
obtain cultures if possible but do not delay antibiotics