Chest Pain 2

Question 1

What type of people does pneumothorax tend to affect?

Answer 1

Tall, young, healthy people. Also associated with smoking, Marfan’s disease, alpha-1 antitrypsin deficiency and changes in atmospheric pressure.

Question 2

Describe pain from a pleural disease and why it’s like that.

Answer 2

Pleural pain is VERY, VERY PAINFUL. The pain is usually sharp and precise. Why? Because the pleura is somatically innervated.

Question 3

What enters the pleural space when you have pneumothorax? What do most patients have with this affliction?

Answer 3

Air. Most patients have a bleb: a collection of air within the layers of the visceral pleura. Blebs are places where the lung has rotted as a result of emphysema, which leaves huge holes in the lung that are vulnerable to popping and leaking air.

Question 4

What is increased in tension pneumothorax?

Answer 4

Intrapleural pressure.

Question 5

True or false: many patients with pneumothorax are asymptomatic.

Answer 5

TRUE. Especially those with COPD.

Question 6

Patients with what affliction tend to have a high mortality with pneumothorax?

Answer 6

COPD.

Question 7

During tension pneumothorax, increases in pressure above central venous pressure will result in what?

Answer 7

Decreased venous return and hypotension.

Question 8

How should tension pneumothorax be diagnosed?

Answer 8

Clinically.

Question 9

Describe the presentation of tension pneumothorax.

Answer 9

Subcutaneous air, tracheal deviation, shock, severe respiratory distress, early morning discovery.

Question 10

What are some presentations of pneumothorax?

Answer 10

Chest pain which is pleuritic, subacute course, mild dyspnea, decreased breath sounds unilaterally, tympanitic hemithorax, absent tactile fremitis, Hamman’s crunch.g

Question 11

What are the presentations of pleural effusion?

Answer 11

Pleural effusions may be asymptomatic, but can also cause: chest pain, dyspnea, decreased breath sounds, dullness to percussion and mediastinal shift (in large effusions).

Question 12

Which chest x-ray, AP or lateral, requires more fluid to accumulate before being visible on film?

Answer 12

AP. You need 500 ccs vs 200 ccs for lateral. This is because there exists a deep sulcus laterally that allows for greater visibility, whereas the fluid on the AP film is also lined behind the liver.

Question 13

How can you detect a free flowing effusion on x-ray?

Answer 13

Have the patient lie down on his side. If the lung opens up, the pleural effusion is free flowing.

Question 14

What can be done to both diagnose and treat pleural effusion?

Answer 14

Thoracentesis. This can ONLY be done with ultrasound guidance.

Question 15

Empyemas are most commonly caused by which organisms?

Answer 15

Staph, strep and Gram negative organisms.

Question 16

What can empyemas occur after?

Answer 16

Pneumonia, lung infarction, resection or abdominal infection.

Question 17

What two things should lead you to suspect an empyema?

Answer 17

Fever and pleural effusion.

Question 18

How do you treat an empyema?

Answer 18

With antibiotics and drainage.

Question 19

What is a sign of pneumomediastinum on imaging?

Answer 19

If you can see the two diaphragms coming all the way to the vertebrae, with no heart in the middle, it means that the mediastinum is filled with air.

Question 20

What are risk factors for thrombotic emboli?

Answer 20

Trauma, immobilization, cancer, surgery, birth control pills.

Question 21

What is a sign in imaging that could aid in the diagnosis of a pulmonary emboli?

Answer 21

Hampton’s hump.

Question 22

What are three examples of ischemic heart disease?

Answer 22

Myocardial infarction, angina pectoris and heart failure.

Question 23

What is a strong prognosticator of death in chest pain?

Answer 23

Congestive Heart Failure

Question 24

Are infarcts always symptomatic?

Answer 24

No. About 1/4-1/3 of all infarcts are silent.

Question 25

How sensitive are H/Ps and EKGs when it comes to diagnosing an MI?

Answer 25

Very sensitive (about 96%). Can get even more sensitive (98%) with serum markers. Adding one more test can bring it up to 99%. EKG abnormalities on their own are not that sensitive. All tests serve to increase sensitivity and decrease specificity.

Question 26

EKGs and cardiac enzymes can diagnose MI, but they can’t do what?

Answer 26

Tell you who is safe to discharge.

Question 27

True or false: a discharged MI has more than twice the mortality rate as an admitted one.

Answer 27

True.

Question 28

What are some non-atheromatous causes of MI?

Answer 28

Arteritis, syphilis, amyloidosis, congenital anomalies of coronary arteries, toxins and emboli.

Question 29

What physical exams are mandatory if a patient walks in complaining of chest pain?

Answer 29

Heart, lung and vascular.

Question 30

What does an ST elevation signify?

Answer 30

Acute ischemia/injury

Question 31

What does an ST depression signify?

Answer 31

Can be ischemia, but can also be reciprocal change or something non-specific.

Question 32

What does a pathologic (i.e. prolonged) Q wave signify?

Answer 32

Previous infarction, because they take several hours to days to develop.

Question 33

How long do physicians have to obtain and interpret an EKG?

Answer 33

10 minutes

Question 34

What are some non-MI causes of ST elevation?

Answer 34

• Early repolarization
• LVH
• Inferior vena cava diameter/paced rhythms
• Pericarditis/myocarditis
• Hypothermia
• LV aneurysms

Question 35

What are some non-MI causes of ST depression?

Answer 35

• Hypokalemia
• Digoxin effect
• Cor Pulmonale
• LVH
• IVCD/paced rhythms

Question 36

What are some non-ischemic causes of T-wave inversions

Answer 36

• Peds EKGs
• IVCD/paced rhythms
• Any other myocardial disease
• Intracranial pathology
• Cor pulmonale
• Many others

Question 37

What are some therapies for MI?

Answer 37

Nitroglycerin, morphine, aspirin/platelet inhibitors, anticoagulants, thrombolytics, surgical revascularization.

Question 38

What are some acute complications of MI? Which is the most common?

Answer 38

• Arrythmias (most common)
• Congestive left sided heart failure (also comomon)
• Cardiogenic shock
• Mural thrombosis and systemic thromboembolism.
• Ventricular rupture
• Papillary muscle infarction
• Fibrinous pericarditis (very common, but not significant)
• Deformation of heart wall (can lead to aneurysm)