Chest Pain

Question 1

Describe somatic pain.

Answer 1

Sharp, hot, well-localized

Question 2

Describe visceral pain.

Answer 2

Difficult to describe, poorly localized

Question 3

What is the most common reason people seek medical care?

Answer 3

PAIN

Question 4

What are the five things you should always ask about pain?

Answer 4

1. Nature of pain
2. Aggravating and alleviating factors
3. Radiation of pain
4. Time course of pain
5. Location

Question 5

What is a classic presentation of a heart problem?

Answer 5

Old ladies with bilateral arm pain.

Question 6

What is the one thing you ABSOLUTELY CANNOT get wrong in the patient’s history?

Answer 6

Dyspnea. It means the body is looking for more oxygen.

Question 7

What does metabolic acidosis mean?

Answer 7

Oxidative phosphorylation is not working properly.

Question 8

What can you use to detect the silent parts of the heart that an EKG might miss?

Answer 8

Echocardiogram.

Question 9

What are the diagnostic studies you can use to diagnose chest pain?

Answer 9

Hct, chemistries, urinalysis, cardiac markers, D-dimer, EKG, chest x-ray, CT-imaging, stress testing, angiography.

Question 10

What cause of chest pain do you want to rule out right away?

Answer 10

Musculoskeletal pain. This is why you always start the exam with this.

Question 11

What are two causes of abdominal pain?

Answer 11

Cholecystitis and ectopic pregnancy.

Question 12

What are some causes of esophageal pain? Which is the most serious?

Answer 12

Causes can include spasm, GERD and improper swallowing of food, but a rupture is the most serious. This can result in bleeding and food getting caught in the mediastinum; in many ways, this is worse than an MI.

Question 13

What are a few sources of cardiovascular chest pain?

Answer 13

Acute Coronary Syndrome, Aortic Dissection and Pericarditis

Question 14

What are some respiratory causes of chest pain?

Answer 14

Pleural effusion, pneumothorax, pneumonia and pleurisy

Question 15

Should some patients be treated before a definitive diagnosis is made?

Answer 15

YES

Question 16

Classic presentations are rare, true or false?

Answer 16

Sadly, true.

Question 17

Does a therapeutic response imply a diagnosis?

Answer 17

No.

Question 18

What is a “good story” and what is a “bad story”?

Answer 18

A good story means the patient’s history and symptoms are strongly suggestive of ischemia, which is life-threatening. A bad story is not suggestive of a life-threatening disease.

Question 19

What is an intramural hematoma?

Answer 19

A dissection that is not actively growing. This is obviously a preferable diagnosis.

Question 20

Describe aortic ulcers.

Answer 20

They are an ulceration of the aorta from atheromatous plaques. They can eventually lead to dissection.

Question 21

What is the most common cause of dissection?

Answer 21

Hypertension

Question 22

What are some other causes of dissection?

Answer 22

Connective tissue disease, pregnancy, congenital cardiac abnormalities (bicuspid aortic valve, coarcatation, Ebstein’s abnormality), aortic ulcers/crypts.

Question 23

What are two UNLIKELY causes of dissection.

Answer 23

Atherosclerosis and trauma

Question 24

What is a very good indicator of dissection?

Answer 24

A sharp chest pain radiating to the back, resulting in mid-scapular pain.

Question 25

What are some presentations of dissection?

Answer 25

Pain in back only, pain that commonly moves, pain that radiates to neck, jaw, arms or lumbar area, syncope (10-12%), neurologic defects, end organ ischemia.

Question 26

What are some findings on a physical exam that indicate a dissection?

Answer 26

Pulse defects (pretty good hint- 20%), aortic insufficiency, tamponade, altered mental status (not that helpful), hemiplegia/paraplegia, Horner’s syndrome.

Question 27

Why should you be careful when using an EKG to diagnose a dissection?

Answer 27

EKGs are normal in about 30% of dissections.

Question 28

Why are chest x-rays useful for diagnosing dissection? What are some things they can identify?

Answer 28

CXR is very commonly abnormal (87%), but usually in a non-specific manner. You can see:

• Mediastinal widening (absence of which is a good indicator of no thoracic aortic aneurysm being present)
• Bulging aortic contour
• Pleural effusions
• Intimal calcium sign

Question 29

What advanced imaging can you use to detect a dissection?

Answer 29

CT, Angiogram and Transesophageal Echocardiogram

Question 30

What is one way the aorta can look abnormal on imaging?

Answer 30

It can get wider as it gets closer to the base. A normal aorta is uniform throughout.

Question 31

How do you treat an Ascending Aortic Dissection?

Answer 31

Surgery in order to prevent tamponade, as long as it’s not contraindicated by another health condition (i.e. metastatic cancer). All dissection surgeries have a very low chance of survival, but often, it is the ONLY choice people have.

Question 32

How do you treat a Descending Aortic Dissection?

Answer 32

There’s no easy answer. Surgery is controversial, because a ruptured abdominal aorta will leak blood into the abdomen, which is bad, but at least keeps the blood in one compartment. By performing surgery, you cut the abdomen open and release the pressure, causing all the blood to leak out, killing the patient.