Chest Pain Flashcards
Some common causes of chest pain: (MACER)
- Musculoskeletal
- Abdo (cholecystitis, ectopic preggers)
- Esophageal (rupture, spasm, GERD)
- Cardiovascular (ACS with angina, unstable angina, MI, LV; Aortic dissection, pericarditis, valvular heart disease)
- Respiratory (PE, PTX, pneumonia, pleural)
Five things you ask on chest pain; rest of history:
- Nature of pain
- Aggravating and alleviating
- Radiation of pain
- Time course of pain
- Location;
fever, cough, dyspnea (exertion, at night?), extremity/trunk pain?;
PMH, atherosclerosis?, coagulopathy/hypercoag, connective tissue disease, FH, meds?
PE:
- HEENT
- Neck (JVD, carotid pulse, bruits)
- Breath, heart sounds
- PUlses!!
- Hands on chest, back, CVA, abdo
- Edema, venous cords, hair pattern (not enough blood there)
Some diagnostic studies:
- Hct, chemistries, UA
- Cardiac markers, D-dimer
- EKG
- CXR, CT
- Stress test (non-specific for looking at coronary arteries)
- Angiography (invasive)
Aortic disease: dissection:
Etiology: HTN, Marfan’s, pregnancy, congenital cardiac abnormalities;
Think sharp chest pain radiating to back, but can go to neck, jaw, arms, or lumbar area; sometimes just pain in back; sometimes the blood gets back into intima from media and there’s a “cure” but if blood goes through adventitia, person DIES!!
SPECIFICALLY: pulse defects is VERY SPECIFIC; look for aortic insufficiency, tamponade, maybe Horner’s or altered mental status;
Use EKG, with CXR to find abnormalities (but nonspecific); advanced imaging includes CT, angiogram, TEE
Pneumothorax: pleural disease
If air enters pleural space, it can be resorbed OR result in pneumothorax; you can have bleb because wall tension increases with radius;
spontaneous (primary, non-traumatic event) vs. tension (increased intrapleural pressure above central venous pressure);
1. Spontaneous: think thin small males (on airplane, Marfan’s, smoker)
2. Tension: increases of pressure above CVP resulting in decreased venous return and hypotension;
presents: chest pain is pleuritic, maybe mild dyspnea and Hamman’s crunch (air in mediastinum can lead to crunching sign with heart movement)
Pleural effusion: pleural disease:
think chest pain, dyspnea, dullness to percussion, decreased breath sounds; Cddd
think of changes in hydrostatic, oncotic pressure, capillary perm;
look at CXR (sensitive); decubitus film shows if effusion is free-flowing (lay them on SIDE)
Empyema:
if you have fever and pleural effusion, TREAT WITH ANTIBIOTICS AND DRAINAGE
Pericarditis:
- positional pain (you lean forward toward chest wall)
- pericarditis always with some myocarditis
- four stages of EKG progression
- maybe viral, rheum, uremic, traumatic, post MI (RUMTV);
look for ST segment elevation in various leads;
see electrical alternans (seen in V3 lead, and think pericardial disease)
Pneumomediastinum:
- air comes from esophagus, trachea, bronchi, neck, or abdomen;
- Hamman’s sign!!
coughing and you don’t cough something out and you rupture something
PE: risk factors and scoring:
- Surgery
- Immobilization
- Trauma
- Cancer (pancreatic)
- BCP (birth control pills);
Well’s
Sit Chris Bosh
Epigastric pain often
sensed in the chest
EKG, cardiac enzymes can
diagnose MI but CANNOT tell you who is safe to discharge
Nonatheromatous MI:
Arteritis Toxins Emboli Syphilis Amyloidosis Congenital anomalies of coronary arteries
ATE a SAC of fruit
EKG:
- ST elevation = injury
- ST depression = reciprocal change or nonspecific
- Q wave = infarction;
abnormal myocardium is more positive at the end of depol than normal myocardium
