chest pain

Question 1

cardiac pain

Answer 1

myocardial ischaemia or infarction
cantral, tight or heavy
may radiate to the jaw or left or right arm

Question 2

vascular pain

Answer 2

aortic dissection

very sudden onset, radiates to the back

Question 3

pleuropericardial pain

Answer 3

pericarditis +- myocarditis 
infective pleurisy 
pneumothorax 
pneumonia 
autoimmune disease 
mesothelioma 
metastatic tumour

Question 4

pericarditis and myocarditis

Answer 4

pleuritis pain, worse when the patient lies down

Question 5

infective pleurisy

Answer 5

pleuritic pain

Question 6

pneumothorax

Answer 6

sudden onset, sharp, associated with dyspnoea

Question 7

autoimmune disease

Answer 7

pleurtic pain

Question 8

pneumonia

Answer 8

often pleuritic associated with fever and dysponea

Question 9

mesothelioma

Answer 9

sever and constant

Question 10

metastitic tumour

Answer 10

severe and constant, localised

Question 11

chest wall pain may be due to

Answer 11

persistant cough 
muscular strains 
intercostal myositis 
thoracic zoster 
coxsackie B virus infection 
thoracic nerve compression or nfiltration 
rib fracture 
rib tumour, primary or metastatic 
tietze syndrome

Question 12

persistant cough

Answer 12

worse on movement

chest wall tender

Question 13

muscular strains

Answer 13

worse with movement, chest wall tender

Question 14

intercostal myositis

Answer 14

sharp, localised, worse with movement

Question 15

thoracic zoster

Answer 15

severe, follows nerve root distribution, precedes rash

Question 16

coxsackie B virus

Answer 16

pleuritic pain

Question 17

thoracic nerve compression or infiltration

Answer 17

follows nerve root distribution

Question 18

rib fracture

Answer 18

history of trauma, localised tenderness

Question 19

rib tumour, primary or metastitic

Answer 19

constant, severe, localised

Question 20

tietze syndrome

Answer 20

constal cartilage tender

Question 21

GI pain may be due to

Answer 21

gastro-oesophageal reflux

diffuse oesophageal spasm

Question 22

gastro oesophageal reflux

Answer 22

not related to exertion, may be worse when patient lies down, may wake patient at night (common)

Question 23

diffuse oesophageal spasm

Answer 23

relieved by swallowing eg. warm water

Question 24

airway pain may be due to

Answer 24

tracheitis
central bronchial carcinoma
inhaled foreign body

pain in throat, breathing painful

Question 25

central pain may be due to

Answer 25

panic attacks - often preceeded by anxiety, associated with breathlessness and hyperventilation symtpoms (dizziness, perioral paraesthesia)

Question 26

mediastinal pain may be due to

Answer 26

mediastinitis sarcoid adenopathy lymphoma prolonged pain

Question 27

orthopnoea

Answer 27

dyspnoea when lying down flat

Question 28

SOB awakening patient

Answer 28

paroxysmal noctural dysponoea

Question 29

pain in the calf enduced by excercise and relived at rest

Answer 29

intermittant claudication

Question 30

important heart related conditions on past history

Answer 30

myocardial infarction, coronary artery bypass grafting (CABG), coronary angioplasty, cardiac pacemaker or defib, ablation treztment for cardiac arythmia, rheumatic fever, chorea, recent dental work, thyroid disease prior medical examination revealing heart disease drug treatment (chemotherapy with alkylating agent or 5-flurouracil 5FU

Question 31

improtant findings on family history

Answer 31

myocardial infarcts, cardiomyopathy, congenital heart disease, mitral valve prolapse, marfan syndrome

Question 32

unusual coronary artery disease risk factors

Answer 32

erectile dysfunction rhuematoid arthritis and chronic inflammatory rheumatological disease male sex and advanced age

Question 33

pain from angina is caused by

Answer 33

accumulation of ischameic metabolites from complete or partial obstruction of coronary artery

Question 34

character of chest pain

Answer 34

tight or heavy - angina sharp or stabbing - pericarditis or pleurisy burning - acid reflux

Question 35

onset of pain

Answer 35

predictable with exertion - angina | not exertional - all others

Question 36

relieving factors

Answer 36

relived by rest and by nitrates - angina

Question 37

positional pain

Answer 37

not positional - angina worse supine - pericarditis onset may be when supine - relux

Question 38

affect with respiration

Answer 38

not affected by respiration - angina or relfux | worse with respiration - pericardial or pleural rub

Question 39

elements of history which discriminate for MI over angina

Answer 39

``` onset at rest severe pain sweating anxiety no relief with nitrates associated synmptoms - nausea and vomiting ```

Question 40

factors discriminating for aortic dissection over myocardial infarction

Answer 40

radation to the back instantaneous onset tearing quality of pain history of marfans disease or ehlers - danlos syndrome

Question 41

factors discriminating for chest wall pain over myocardial ischameia

Answer 41

``` positional worse at rest prolonged localised chest wall tenderness ```

Question 42

some questions to ask with chest discomfort suspected angina

Answer 42

1. sharp, dull, heavy or tight 2. does it come on with physical exercise 3. how loong does it last 4. where do you feel it 5. does it make you stop or slow down 6. does it go away quickly when you stop exercising 7. does it come on at rest 8. have you had angina before and does this feel the same

Question 43

unstable angina

Answer 43

change in the previous pattern of onset of previously stable angina

Question 44

angina should be relieved by

Answer 44

rest or GTN spray

Question 45

duration of pain

Answer 45

<30 mins - angina >30 mins - acute coronary syndrome > many days - neither

Question 46

pleuritic pain

Answer 46

worse on inspiration may be due to pleurisy or pericarditis not brought on by exertion relived by sitting up and leaning forward caused by movement of inflamed pleural or pericardial surfaces

Question 47

pleurisy

Answer 47

may occur because of inflmmation of the pleura as a primary problem (viral infection) or secondary to pneumonia or pulmonary embolism

Question 48

factors favouring massive pumonary embolism

Answer 48

collapse, dyspnoea, cyanosis | often pleuritic