Assessment of CP Flashcards
What are the common etiologies of CP?
Angina MI Pericarditis Dissection Aortic Aneurysm Pleuritic pain Radiating pain from other causes
What is the first step in assessing chest pain?
Quantify the pain
If you have a patient with a tearing, shearing pain radiating to the back, what should you think of immediately?
Aortic dissection! Until proven otherwise
What type of chest pain is typically sharp, stabbing, unilateral, and made worse with a deep breath?
Pleuritic pain
What is pleuritic pain associated with?
Fever, cough, SOB, infectious process like pneumonia
What causes the chest pain of angina?
Due to ischemia of the heart muscle - usually spasm of coronary arteries
If your patient presents with chest tightness or constricting pain, and says they have an “elephant sitting on their chest” what should you think?
Angina
Who might have atypical presentations of angina?
Women and diabetics
Dull Tight Pressing Squeezing Burning Heaviness Band across the chest Weight in center of chest
Angina symptoms
What are some associated symptoms of angina?
Dyspnea, radiation, pain during exertion that abates with rest, exacerbating factors like cold, heavy meals and emotion
What are the some relieving factors for angina?
Rest and nitrates
If your patient is having new onset chest pain that occurs with minimal exertion and does not get better with rest that is increasing in intensity, what type of angina do they have?
Unstable!
Unstable angina is associated with??
Ruptured plaques and thrombi, causing obstruction
Stable angina is associated with?
Chronic stable coronary stenosis
What provokes chronic stable angina?
Exertion
What are the angina equivalents that a patient may have that could clue you in to CVD or an MI?
Dyspnea, indigestion, weakness, malaise
Who is more likely to present with angina equivalents?
Women
What condition would give a patient tearing pain that lasts for hours and gets worse with changing body positions and breathing?
Pericarditis
Which disorders put a patient at risk for pericarditis?
Lupus, RA, kidney failure, cancer, trauma
What will relieve the pain of pericarditis? What makes it worse?
Leaning forward
Laying down
What is important during your exam to identify pericarditis?
History of recent illness
Friction rub on auscultation
What type of imaging should you use to distinguish pericarditis from and MI?
ECHO
Can mimic MI on ECG
What is Beck’s triad?
Helps identify cardiac tamponade
Low BP
Distended neck veins
Muffled heart sounds
What is a complication of pericarditis that results from the buildup up pressure from fluid in the pericardial sac that restricts the blood returning to the heart?
Cardiac tamponade
How do you know if someone is having an aortic dissection?
BP is different on left and right side
What could an aortic dissection be confused with?
MI, esophagitis, or pericarditis
Which pulses will be lost on the left or right side with an aortic dissection?
Radial, femoral, pedal pulses will be different
Where will you hear a heart murmur for a patient having an aortic dissection?
Usually aortic valve
What causes paralysis or stroke during a dissection?
Blood vessels exiting the aorta are damaged
What risk factors should you ask about when obtaining a history for chest pain?
CAD - HTN, smoking, hyperlipidemia, diabetes, family history
What risk factors should you ask about for PE?
Recent surgery Fractures Prolonged inactivity (long flights or bed rest) OCP Cancer
What are some risk factors you should ask about when assessing for an aortic dissection?
HTN Marfans syndrome Ehlers-Danlos syndrome Polycystic kidney disease Pregnancy Cocaine use
Extreme laxity of joints
Ehlers-Danlos syndrome
What is the sequence of exam when auscultating the heart for chest pain?
Supine with head of bed at 30 degrees
Left lateral decubitus
Sitting, leaning forward
S1 results from?
Closure of mitral valve
Where is S1 the loudest?
Apex fo heart
S2 results from?
Closure of aortic valve
Where is S2 the loudest?
Base of heart
When will you hear A2 and P2? What is it?
Heard during inspiration, splitting of S2
Caused by abrupt acceleration of inflow across mitral valve?
S3 “gallop”
Caused by increased LV and diastolic stiffness
S4
S3 and S4 are highly correlated with?
HF and MI
When do you use the diaphragm to auscultate?
High-pitched S1 and S2
Aortic and Mitral regurg
Pericardial friction rub
When do you use the bell to auscultate?
Low pitched S3 and S4
Mitral stenosis murmer
What is the grading scale for a murmer?
1-6
6 = very loud!
What can you find on a skin exam of someone with hypercholesterolemia?
Xanthomas
What cardiac biomarkers are released with myocardial cell death?
Troponins and CK-MB
What is the preferred biomarker for assessing an AMI because it is more specific and sensitive?
Troponin
If you have a patient with CP and no elevation of Troponin or CK-MB, can you diagnose them with an AMI??
No! Elevation of troponin or CK-MB is required for diagnosis of AMI
When should you check the troponin on a patient with chest pain?
At first presentation
4-6 hours if first is normal
12-24 hours high level of suspicion
When should troponin levels increase?
within 3-12 hours from pain onset
Peak at 24-48 hours
Return to baseline 5-14 days
If your patient has ST-segment elevation on ECG and ischemic chest pain, do you wait for troponin results to treat them?
No! Still draw the troponin but treat them right away with thrombolytics or coronary angioplasty
What labs do you check for heart failure?
BNP or N-terminal pro-BNP
Should you compare previous BNP or NT-proBNP from prior visits when trying to look for heart failure?
No! Different reference ranges and different assays
Do all patients with symptomatic HF have high plasma BNP or NT-proBNP?
No, not all patients with HF have it and not all asymptomatic patients have low values
What can help you guide management of acute HF?
Serial BNP
Ordering lipid panels for screening purposes is _____ prevention
Primary
Ordering lipid panels for monitoring purposes is _____ prevention
Secondary
What is the total cholesterol goal?
Less than 200
What is the HDL cholesterol goal?
Greater than 60
What is the LDL cholesterol goal?
Less than 100 for those at risk for heart disease, less than 70 for those who have heart disease
What is the triglyceride goal?
Less than 150
What 3 diagnoses do you not want to miss because they are medical emergencies and can all present with chest pain?
MI
PE
Aortic dissection
Red flags with chest pain
Severe, unrelenting sub-sternal pain Unstable vitals Moderate - Severe sSOB Diaphoresis, anxiety Patient voices feeling impending doom
Optimal BMI?
18.5-24.9
Where does pain usually radiate to with angina?
Left arm and shoulder
High-pitched, grade 2/6, blowing decrescendo diastolic murmur, heard best in the 4th ICS with radiation to the apex
Aortic regurgitation
