Chest Pain Flashcards
MI
-Cardiac-sounding pain
=heavy, central chest pain they may radiate to the neck and left arm
=nausea, sweating
=elderly patients and diabetics may experience no pain
Risk factors for cardiovascular disease
P: Traditionally described as sudden onset of central, crushing chest pain. It may radiate into the neck and down the left arm. Signs of autonomic dysfunction may be present. The presenting features may be atypical in the elderly and those with diabetes.
D: Diagnosis is made through identification of new and usually dynamic ECG changes (and cardiac enzyme changes). Inferior and anterior infarcts may be distinguished by the presence of specific ECG changes (usually II, III and aVF for inferior, leads V1-V5 for anterior).
M: Treatment is with oral antiplatelet agents, primary coronary angioplasty and/ or thrombolysis.
Pneumothorax
-History of asthma, Marfan’s etc
-Sudden dyspnoea and pleuritic chest pain
-Symptoms — sudden-onset pleuritic pain and breathlessness in people with or without pallor and tachycardia.
-Signs — reduced chest wall movements, reduced breath sounds, reduced vocal fremitus, and increased resonance of the percussion note on the affected side. Tension pneumothorax can result in rapid development of severe symptoms associated with tracheal deviation away from the pneumothorax, tachycardia, and hypotension.
PE
-Sudden dyspnoea and pleuritic chest pain
-Calf pain/swelling
-Current combined pill user, malignancy
P: Typically sudden onset of chest pain, cough, , syncope?, haemoptysis, hypoxia and small pleural effusions may be present.
Most patients will have an underlying deep vein thrombosis
Signs: tachypnoea of more than 20 breaths per minute, tachycardia, mild pyrexia, signs of deep vein thrombosis (DVT).
D: Diagnosis may be suggested by various ECG findings including S waves in lead I, Q waves in lead III and inverted T waves in lead III. Confirmation of the diagnosis is usually made through use of CT pulmonary angiography.
M: Treatment is with anticoagulation, in those patients who develop a cardiac arrest or severe compromise from their PE, consideration may be given to thrombolysis
Pericarditis
-Sharp pain relieved by sitting forwards
-May be pleuritic in nature
-Symptoms — sharp, constant sternal pain relieved by sitting forward. Pain may radiate to the left shoulder and/or left arm and/or into the abdomen, and is worse when lying on the left side and on inspiration, swallowing, and coughing. Other symptoms may include fever, cough, and arthralgia. Cardiac tamponade may have associated breathlessness, dysphagia, cough, and hoarseness.
-Signs — pericardial friction rub (high pitched scratching sound, best heard over the left sternal border during expiration). Signs of cardiac tamponade include pulsus paradoxus (decrease in palpable pulse and arterial systolic blood pressure of 10 mmHg on inspiration); and hypotension, muffled heart sounds, and jugular venous distention (Beck’s Triad).
Dissecting aortic aneurysm
-‘Tearing’ chest pain radiating through to the back and intrascapular region
-Unequal upper limb blood pressure
-Mech: This occurs when there is a flap or filling defect within the aortic intima. Blood tracks into the medial layer and splits the tissues with the subsequent creation of a false lumen. It most commonly occurs in the ascending aorta or just distal to the left subclavian artery (less common).
-E: It is most common in Afro-carribean males aged 50-70 years.
P: Patients usually present with a tearing intrascapular pain, which may be similar to the pain of a myocardial infarct.
The dissection may spread either proximally or distally with subsequent disruption to the arterial branches that are encountered.
In the Stanford classification system the disease is classified into lesions with a proximal origin (Type A) and those that commence distal to the left subclavian (Type B).
Signs: high blood pressure, blood pressure differentials (different in both arms), inequality in pulses (carotid, radial, femoral), a new diastolic murmur (aortic valve regurgitation), and occasionally a pericardial friction rub. Neurological deficits may be present (such as hemiplegia).
D: Diagnosis may be suggested by a chest x-ray showing a widened mediastinum. Confirmation of the diagnosis is usually made by use of CT angiography
M: Proximal (Type A) lesions are usually treated surgically, type B lesions are usually managed non operatively.
GORD
-Burning retrosternal pain
-Other possible symptoms include regurgitation and dysphagia
-Symptoms — sub-sternal pain, which commonly occurs at night or after consumption of a large meal. Epigastric pain often radiates to the throat and is worse when bending or lying flat. Regurgitation of acid and food into the mouth can occur.
Musculoskeletal chest pain
-One of the most common diagnoses made in the Emergency Department.
-The pain is often worse on movement or palpation.
May be precipitated by trauma or coughing
Costochondritis
=Symptoms — unilateral, sharp, anterior chest-wall pain, exaggerated by breathing, activity, or a particular posture. Usually preceded by exercise or an upper respiratory tract infection, and can last for months.
=Signs — tenderness over the costochondral junction and pain in the affected area when palpating the chest wall. In Tietze’s syndrome, there is a tender, fusiform swelling of the costal cartilage at the costochondral junction.
-Rib fracture
=History — previous history of trauma or coughing.
=Symptoms — unilateral, sharp chest pain, worse with inspiration.
=Signs — bruising and tenderness on palpation over the affected rib.
Shingles
Pain often precedes the rash
Perforated peptic ulcer
-Patients usually develop sudden onset of epigastric abdominal pain, it may be soon followed by generalised abdominal pain.
-There may be features of antecendant abdominal discomfort, the pain of gastric ulcer is typically worse immediately after eating.
-Diagnosis may be made by erect chest x-ray which may show a small amount of free intra-abdominal air (very large amounts of air are more typically associated with colonic perforation).
-Treatment is usually with a laparotomy, small defects may be excised and overlaid with an omental patch, larger defects are best managed with a partial gastrectomy.
Boerhaaves syndrome
-Spontaneous rupture of the oesophagus that occurs as a result of repeated episodes of vomiting.
-The rupture is usually distally sited and on the left side.
-Patients usually give a history of sudden onset of severe chest pain that may complicate severe vomiting. Subcutaneous emphysema on chest wall.
-Severe sepsis occurs secondary to mediastinitis.
-Diagnosis is CT contrast swallow.
-Treatment is with thoracotomy and lavage, if less than 12 hours after onset then primary repair is usually feasible, surgery delayed beyond 12 hours is best managed by insertion of a T tube to create a controlled fistula between oesophagus and skin.
-Delays beyond 24 hours are associated with a very high mortality rate.
Acute congestive heart failure
-Symptoms — ankle swelling, tiredness, severe breathlessness, orthopnea, and coughing (rarely producing frothy, blood-stained sputum).
-Signs — elevated jugular venous pressure, gallop rhythm, inspiratory crackles at lung bases, and (often) wheeze.
Arrhythmias
-Symptoms — chest pain associated with palpitations, breathlessness, and syncope (or near syncope).
-Signs — bradycardia or tachycardia.
CAP
-Symptoms — cough and at least one other symptom of sputum, wheeze, dyspnoea, or pleuritic chest pain.
-Signs — any focal chest sign (such as dull percussion note, bronchial breathing, coarse crackles, or increased vocal fremitus or resonance) plus at least one systemic feature (such as fever or sweating, myalgia), with or without a temperature greater than 38°C. There may be signs of an associated pleural effusion.
Asthma
-Symptoms — wheeze, breathlessness, cough. Symptoms are variable (often worse at night, first thing in the morning, and upon exercise or exposure to cold or allergens).
-Signs — there may be none when the person is feeling well. During an acute episode, the respiratory rate is increased, and wheeze is usually present.
Lung or lobar collapse
-Symptoms — localized chest pain, breathlessness, cough.
-Signs — reduced chest wall movement on the affected side, dull percussion note with bronchial breathing, reduced or diminished breath sounds.
