Chest Pain

Question 1

Cardiac differentials of chest pain

Answer 1

Coronary artery diseases
Pulmonary hypertension
Aortic valve disease
Mitral valve prolapse
Pericarditis
Hypertrophic cardiomyopathy
Myocarditis

Question 2

Pulmonary differentials of chest pain

Answer 2

Pulmonary embolism
Pneumonia
Pleurisy
Pneumothorax

Question 3

Emotional, vascular and neurological differentials of chest pain

Answer 3

Emotional: anxiety and depression
Vascular: aortic dissection and aortic aneurysm
Neurological: cervical nerve root and zoster

Question 4

Musculoskeletal differentials of chest pain

Answer 4

Costochondritis
Arthritis
Muscular spasm
Bone tumour

Question 5

GIT differentials of chest pain

Answer 5

Peptic ulcer
GORD
pancreatic
Cholecystitis

Question 6

Normal ECG

Answer 6

Sinus rhythm
Normal QRS complex and normal ST segment and T-waves

Question 7

Normal structure of arteries

Answer 7

Intimate, media and adventitia(atherosclerosis relevance)

Question 8

Risk factors for chest pain (modifiable and non modifiable)

Answer 8

Non modifiable:
Age, gender, family history
Modifiable
High blood cholesterol
High blood pressure
Diabetes, obesity, physical inactivity
Smoking and poor diet

Question 9

Clinical manifestation of Angina

Answer 9

Retrosternal, severe
Crushing or pressing character
Radiates to arm or jaw
Nausea, vomiting and diaphoresis
Better after nitrates or rest
Worsened by activity

Question 10

Life threatening diferrentials of acute onet of chest pain

Answer 10

Acute coronary syndrome
Pulmonary embolism
Aortic Valve dissection
Tension pneumothorax
Pericardial tamponade
Mediastinitis

Question 11

Atypical presentation manifestation

Answer 11

Older age, male sex, positive fam hx, hx of peripheral vascular disease, presence of risk factors

Question 12

Types of angina

Answer 12

STEMI: persistent ST elevation
NSTEMI: abnormal ST/T and troponinnrise or fall
Unstable angina: no ECG findings and troponin normal

Question 13

Initial therapy of acute coronary syndrome

Answer 13

Oxygen : insufflation 4-8L/min if oxygen sat is less than 90%
Nitrates: sublingual or intravenous (caution if BP systolic is less than 90mmHg)
morphine: 3-5 mg IV/ subcutaneous if severe pain)

Antithrombotic treatment
Aspirin: antiplatelet initial 150-300mg non enteric formulation followed by 75-100mg per day
P2Y12 inhibitor: platelet inhibitors loading dose of ticapleror or clopidogrel

Question 14

Troponin markers

Answer 14

> diagnosis or stratify risk
Specific and sensitive to cardiac tissue
Initial rise occurs within 4 hrs after symptom onset and remain elevated for up to 2 weeks.negative predictive value of negative hsTropT on admission bis more than 95%.
Repeat at 3 hrs

Question 15

Risk scores used

Answer 15

GRACE and TIMI