CARDIOPULMO - CHEST PAIN Flashcards
Memorise
Differentials of chest pain
- Angina d/t Anemia
- Unstable Angina
- Angina
- Myocardial Infarction
- Pericarditis
- Pulmonary Embolism
- Spontaneous Pneumothorax*
- Atypical Pneumonia
- Herpes Zoster
- Gord
CVS MI Angina Arrhythmia Aortic dissection Pericarditis
Pulmo Pulmonary embolism Pneumothorax Pneumonia Pleural effusion
Gastro
PUD
GORD
Herpes zoster Costochondritis Anxiety Trauma Psychogenic
Key History - CHEST PAIN
This needs to be meticulous because of the life-threatening causes. Analyse the pain into its usual characteristics with the SOCRATES system. Note family history drug history, psychosocial history and past history, especially if immunocompromised (e.g. diabetes or metabolic syndrome)
Key examination - CHEST PAIN
- General appearance
- Vital signs
- Peripheral circulation
- Careful examination of cardiovascular and respiratory systems
- Upper abdominal palpation
Key investigations - CHEST PAIN
Base tests available to the GP are ECG, cardiac enzymes and CXR and in most instances help confirm the diagnosis.
•Otherwise specialist investigations including imaging are confined to hospitals and cardiology centres
DIAGNOSTIC TIP - CHEST PAIN
Consider chest pain as due to a coronary syndrome until proved otherwise.
•The history remains the most important clinical factor in the diagnosis of ischaemic heart disease and other conditions.
•With angina a vital clue is the reproducibility of the symptom
CHEST PAIN - PERICARDITIS
Introduce
Hemodynamic stability
Are you in pain? Any allergy? Pain medication.
HOPI - Chest Pain
SOCRATES
(Centre of chest radiated to jaw, left arm and back)
(Like a stab)
(Relieved by leaning forwards)
(Worse by lying flat, deep breathing)
(URTI 1 week ago)
(Pericardial rub +ve/ muffled heart sounds)
-ECG (pending)
It had normal rate, regular rhythm and normal P wave. I pointed to all ST elevations in the leads with concavity consistent with Widespread ST elevations in Pericarditis.
DDX
PMH
FH
SADMA
PE GA - Pallor, cyanosis, edema( sacral and pedal), dehydration Vs GE - CVS - s1 s2 heard any added sound - PERICARDIAL FRICTION RUB, murmur JVP, CAROTID BRUIT HEAVES, THRILLS, APEX BEAT PEDAL AND SACRAL EDEMA RS ABD NEURO
INX
ECG AND CARDIAC ENZYMES
FBE, BSL, ESR CRP, VBG
UA
REFER TO CARDIO REG VIA ISBAR METHOD
ASK RECOMMENDATION FRO 2D ECHO, LFT, TFT, KFT
Angina d/t Anemia - History
KP - HISTORY
INTRODUCE
HEMODYNAMIC STABILITY
- HOPI
CHEST PAIN - SIQORAA1
DIZZINESS
Associated symptoms Palpitation SOB Swelling on UL and LL Calf pain Neck pain Shoulder pain Cough BOV, Body weakness, tingling sensation n/v Bloatedness Tummy pain Waterworks and bowelworks (color of stool*) Rash Recent travel Trauma Anxious person
PMH Hypertension, DM, High Lipid, Heart problems. hx of reflux, had chickenpox FH Heart problems, hypertension and DM SADMAHODEC Stress
KP - PE GA - PALLOR, CYANOSIS, EDEMA (SACRAL AND PEDAL), RASH VS - BP, HR REGULARITY, RR, O2, TEMP GE *CVS - S1 S2 HEARD ANY ADDED SOUND, MURMUR HEAVES, THRILLS, APEX BEAT JVP, CAROTID BRUIT SACRAL AND PEDAL EDEMA RS ABD + DRE NEURO
KP INV - *ECG AND CARDIAC ENZYMES CXR FBE,BSL,ESR CRP, VBG, UCE UA
REFER TO CARDIO REG VIA ISBAR METHOD
RECOMMENDATION STRESS TEST, 2D ECHO, LFT, TFT, KFT
MX ADMIT AT HOSPITAL START ON FLUIDS TAKE OUT SOME BLOOD FOR INVESTIGATIONS ECG, CARDIAC ENZYMES, 2D ECHO FBE, ESR, CRP, VBG, BLOOD GROUP AND CROSS MATCHING LFT, TFT, UCE UA SEEN BY CARDIO SPECIALIST AND GI SPECIALIST ENDOSCOPY AND COLONOSCOPY
CHEST PAIN - SPONTANEOUS PNEUMOTHORAX
INTRODUCE HEMODYNAMIC STABILITY ECG O2 HOPI CHEST PAIN - SOCRATES SOB - REST/EXERTION/ DDX PMH FH SADMA
KP PE GA VS GC- <18YO GE RESPI INSPECTION - MOVE WITH RESPIRATION, SCAR PALPATION - CHEST EXPANSION, TRACHEAL POSITION PERCUSSION - HYPERRESONANT AUSCULTATION - AIR ENTRY EQUAL, EQUAL BREATH SOUND, ANY ADDED SOUND, CRACKES AND WHEEZE CVS S1S2 HEARD, ANY ADDED SOUND, MURMUR HEAVES, THRILLS, APEX BEAT JVP, CAROTID BRUIT SACRAL AND PEDAL EDEMA
KP INVI CXR - SHOWS PNEUMOTHORAX ECG FBE,BSL,VBG, ESR-CRP UA
KP MANAGEMENT Management -admit for observation -doing serial x-ray to monitor if there is any increase in the air escaping or lung collapse. -seen by registrar to decide upon management if need chest drainage or not. -once discharge: avoid smoking avoid flying or dying red flags review
Acute Coronary Syndrome - Unstable Angina - Diagnosis
Condition -
Unstable Angina
Unstable angina is chest pain that occurs at rest or with exertion or stress. The pain worsens in frequency and severity. Unstable angina means that blockages in the arteries supplying your heart with blood and oxygen have reached a critical level.
Common
Cause
The principal cause of unstable angina is coronary heart disease caused by a buildup of plaque along the walls of your arteries. The plaque causes your arteries to narrow and become rigid. This reduces the blood flow to your heart muscle. When the heart muscle doesn’t have enough blood and oxygen, you feel chest pain.
Clinical feature
Chest pain not relieved by rest
Angina symptoms include:
chest pain that feels crushing, pressure-like, squeezing, or sharp pain that radiates to your upper extremities (usually on the left side) or back
nausea
anxiety
sweating
shortness of breath
dizziness
unexplained fatigue
Complication
An attack of unstable angina is an emergency and you should seek immediate medical treatment. If left untreated, unstable angina can lead to heart attack, heart failure, or arrhythmias (irregular heart rhythms). These can be life-threatening conditions.
Acute Coronary Syndrome - Unstable Angina - Management
Investigation
- ECG: PR prolonged (1st degree AV block)
- FBE
- BSL/urinary dipstick
- U/E
- BNP: suspecting heart failure (raised JVP and chest pain)
- Cardiac enzymes: normal
- CXR
- Angiogram within 48 hours
Diagnosis and management
- You have a condition called acute coronary syndrome – unstable angina
- Usually prolonged duration and not relieved by rest
- Give MI MONA: Metoclopramide, IVF, morphine, oxygen, nitrates, aspirin
- Admit to CCU
- Refer to cardiologist ASAP
Repeat cardiac enzymes after 6 hours
