Chest Pain

Question 1

enters the CNS at multiple levels without precise mapping and is therefore difficult to locate

Answer 1

visceral pain fibers

Question 2

what kind of fibers is described as an ache, discomfort, or heaviness?

Answer 2

visceral pain fibers

Question 3

enters the CNS at specific levels and maps to specific areas of the parietal cortex and has dermal distribution

Answer 3

somatic pain fibers

Question 4

what kind of fibers is described as a sharp pain that is precisely located?

Answer 4

somatic pain fibers

Question 5

what is the safety net in EM for chest pain? (6)

Answer 5

vital signs + pulse oximetry
defib pads
O2 supplementation
IV access
EKG (at least 1)
+/- aspirin, nitroglycerin

Question 6

what answer to the question “how long does the chest pain last when you have it?” is worrisome?

Answer 6

“several minutes to an hour”

Question 7

what answer to the question “how long does the chest pain last when you have it?” is semi-reassuring?

Answer 7

“few seconds or constant for > 24 hours”

Question 8

what 2 diagnostics are required?

Answer 8

serial EKGs
2-view Chest xray

Question 9

patient disposition if not sick but patient has known heart disease?

Answer 9

admit

Question 10

patient disposition if not sick but patient is elderly with comorbidities?

Answer 10

admit

Question 11

patient disposition if not sick and patient is healthy, young, and does not have any comorbidities?

Answer 11

D/C with close follow up

Question 12

acute coronary syndrome encompasses spectrum from ____ _____ to _____

Answer 12

stable angina
MI

Question 13

characterized as cardiac chest pain at rest

Answer 13

unstable angina

Question 14

characterized as cardiac chest pain with exertion?

Answer 14

stable angina

Question 15

what is the treatment for a STEMI and NSTEMI? (4)

Answer 15

“MONA”

aspirin 324 mg
nitroglycerin
oxygen
morphine

Question 16

what are 4 contraindications to nitroglycerin in a patient with a STEMI or NSTEMI?

Answer 16

phosphodiesterase inhibitors w/in 24 hrs
SBP < 90
bradycardia
right ventricular infarct

Question 17

what is the difference between a STEMI and an NSTEMI?

Answer 17

NSTEMI cannot be confirmed without labs (troponin)

Question 18

what is the treatment for an NSTEMI after it has been confirmed with a troponin level? (2)

Answer 18

admit
enoxaparin (levonox) OR heparin

Question 19

what is the management for chest pain from suspected angina? (3)

Answer 19

treat chest pain
cardiac catheterization
stress test next morning

Question 20

what can be used to assess risk?

Answer 20

HEART score

Question 21

what does the HEART score stand for?

Answer 21

History
EKG
Age
Risk factors
Troponin

Question 22

what is the disposition for HEART score 0-3? (2)

Answer 22

discharge w/ follow up
OR
stress

Question 23

what is the disposition for HEART score 4-6?

Answer 23

admit

Question 24

what is the disposition for HEART score 7 or greater?

Answer 24

interventional candidate

Question 25

what criteria should we start with if PE is suspected?

Answer 25

Wells Criteria

Question 26

what is the next step for PE if the Wells score is 4 or less?

Answer 26

do PERC for possible D-Dimer

Question 27

what is the next step for PE if the Wells score is 4.1 or more?

Answer 27

CT lung angiogram

Question 28

any _____ answer in PERC requires further evaluation with D-Dimer

Answer 28

positive

Question 29

what is the imaging diagnostic of choice for a PE?

Answer 29

CT pulmonary angiography

Question 30

what imaging can be used for PE in pregnant patients or patients with contrast allergy?

Answer 30

V/Q scan

Question 31

what imaging can be done in patients with signs of a DVT?

Answer 31

venous ultrasound

Question 32

which PE patients can be treated empirically?

Answer 32

S/S of PE + documented DVT

Question 33

what is the treatment for a PE?

Answer 33

enoxaparin

Question 34

a patient presents with a sudden onset of ripping or tearing pain radiating through upper back. Physical exam shows a unilateral pulse deficit and neuro deficit. Dx?

Answer 34

aortic dissection

Question 35

what is the imaging of choice for an aortic dissection? what other imaging can help?

Answer 35

CT angiogram (imaging of choice) Chest xray

Question 36

chest xray reveals widened mediastinum, abnormal aortic contour, and pleural effusion. What is the likely diagnosis?

Answer 36

aortic dissection

Question 37

management for aortic dissection? (2)

Answer 37

SURGERY +/- antihypertensive meds (esmolol)

Question 38

a patient presents with a history of sudden onset, sharp substernal chest pain after forceful vomiting. the patient is tachycardic, febrile, dyspneic/diaphoretic. Dx?

Answer 38

boerhaave syndrome (esophageal rupture)

Question 39

what imaging helps diagnose boerhaave syndrome?

Answer 39

CT w/ oral water-soluble contrast

Question 40

management for boerhaave syndrome?

Answer 40

SURGERY

Question 41

what should we prepare for with boerhaave syndrome?

Answer 41

tension pneumothorax

Question 42

air accumulation in pleural space

Answer 42

pneumothorax

Question 43

a patient presents with a sudden onset, sharp, pleuritic chest pain with dyspnea. on physical exam, there is decreased breath sounds and hyperresonance to percussion on the ipsilateral side. Dx?

Answer 43

pneumothorax

Question 44

what is the treatment for pneumothorax that is 3cm or less?

Answer 44

O2

Question 45

what is the treatment for pneumothorax that is more than 3cm?

Answer 45

chest tube

Question 46

occurs when air continues to accumulate in pleural space causing a mediastinal shift

Answer 46

tension pneumothorax

Question 47

a patient presents with tachypnea, hypotension, decreased O2 sat, jugular venous distention and tracheal deviation. Dx?

Answer 47

tension pneumothorax

Question 48

what is the treatment for a tension pneumothorax?

Answer 48

EMERGENT needle thoracostomy chest decompression

Question 49

accumulation of fluid in pleural space

Answer 49

pleural effusion

Question 50

a patient presents with dyspnea, pleuritic chest pain, infectious S/S, has decreased breath sounds with hypo-resonance. Dx? Tx? (2)

Answer 50

pleural effusion admit drain/culture

Question 51

a patient presents with a fever, cough, back pain, pleuritic chest pain, and N/V. Dx?

Answer 51

pneumonia

Question 52

what is the imaging of choice for pneumonia?

Answer 52

chest xray

Question 53

treatment for pneumonia?

Answer 53

antibiotics

Question 54

a patient presents with a sharp, severe, constant pain with a substernal location. it radiates to back, neck, shoulders and is worse with inspiration and while laying flat. it feels better when sitting up and leaning forward. Dx? Management?

Answer 54

pericarditis admit

Question 55

what is the classic finding of pericarditis?

Answer 55

pericardial friction rub

Question 56

what is the classic EKG finding in pericardiits?

Answer 56

diffuse ST-segment elevation w/ PR depression

Question 57

a patient presents with sharp, substernal chest pain, dyspnea, orthopnea, dysphagia, and hoarseness. physical exams shows distant cardiac sounds, JVD, and a pulsus paradoxus. Dx?

Answer 57

pericardial effusion

Question 58

what is the imaging of choice for a pericardial effusion?

Answer 58

bedside U/S

Question 59

what would a chest xray of a pericardial effusion look like?

Answer 59

enlarged radiopaque cardiac silhouette

Question 60

what is the treatment for a hemodynamically unstable cardiac tamponade?

Answer 60

pericardiocentesis

Question 61

what is the treatment for a hemodynamically stable cardiac tamponade?

Answer 61

admit