Chest Pain

Question 0

Radiation to back; unequal BP between arms

Answer 0

Aortic dissection

Question 1

Chest wall tenderness

Answer 1

Costochondritis

Question 2

Chest pain worse with lying flat, better when sitting up; young pt < 40

Answer 2

Pericarditis

Question 3

Epigastric discomfort; pain better with eating

Answer 3

Duodenal ulcer disease

Question 4

Bad taste, cough, hoarseness

Answer 4

GERD

Question 5

Cough, sputum, hemoptysis

Answer 5

Pneumonia

Question 6

Sudden-onset SOB, tachycardia, hypoxia

Answer 6

Pulmonary embolus

Question 7

Sharp, pleuritic pain; tracheal deviation

Answer 7

Pneumothorax

Question 8

What is the best initial test for chest pain?

Answer 8

EKG

Question 9

When do you take cardiac enzymes?

Answer 9

In the ED, after doing an EKG, for acute chest pain.

Never do cardiac enzymes in an office/ambulatory setting or when the chest pain is chronic or stable.

Question 10

What is the most accurate test for costochondritis?

Answer 10

Physical examination

Question 11

What is the most accurate test for aortic dissection?

Answer 11

Chest x-ray with widened mediastinum, chest CT, MRI, or TEE confirms the diagnosis

Question 12

What is the most accurate test for pericarditis?

Answer 12

EKG with ST elevation everywhere and PR depression

Question 13

What is the most accurate test for pneumonia?

Answer 13

Chest x-ray

Question 14

What is the most accurate test for pulmonary embolus?

Answer 14

Spiral CT; V/Q scan

Question 15

What is the most accurate test for pneumothorax?

Answer 15

Chest x-ray

Question 16

Fever with chest pain suggests which 2 diseases as possible causes?

Answer 16

Fever suggests PE or pneumonia as the cause of chest pain.

Question 17

What symptom in the setting of chest pain has the worst prognosis?

Answer 17

Shortness of breath

Question 18

When do you do stress testing?

Answer 18

When the etiology of chest pain is unclear is uncertain and the EKG is not diagnostic. It requires that you can read the EKG and that the pt can exercise.

Question 19

When is stress testing C/I?

Answer 19

If the pt is currently having chest pain.

Question 20

What are some of the causes of EKG abnormalities that make the EKG unreadable?

Answer 20

Reasons for baseline EKG abnormalities include:

• LBBB
• LVH
• Pacemaker use
• Digoxin

Question 21

What are 2 ways to detect ischemia if you cannot read an EKG?

Answer 21

• Nuclear isotope uptake using thallium or sestamibi; decreased uptake indicates dead or hypoperfused myocardium
• Echocardiographic detection of wall motion abnormalities; decreased wall motion during contraction indicates abnormal myocardium

Question 22

How can you detect ischemia if the pt cannot exercise?

Answer 22

Alternate methods of increasing myocardial oxygen consumption are:

• Persantine (dipyridamole) or adenosine in combination with the use of nuclear isotopes such as thallium or sestamibi
• Dobutamine in combination with the use of echocardiography; dobutamine will increase myocardial oxygen consumption and provoke ischemia detected as wall motion abnormalities on an echocardiogram

Question 23

What is the most accurate method of detecting CAD?

Answer 23

Angiography is used to detect the anatomical location of CAD. It is used to detect the presence of narrowing that is best managed with surgery, angioplasty, or other methods of revascularization.

Question 24

What percent stenosis must a vessel be before clinically significant?

Answer 24

Stenosis of less than 50% of the diameter is insignificant. Surgically correctable disease generally begins with at least 70% stenosis.

Question 25

Which medications (3) will lower mortality in chronic angina?

Answer 25

- Aspirin - B-blockers - Nitroglycerin

Question 26

What is a Holter monitor used for?

Answer 26

Holter monitoring mainly detects rhythm disorders (eg atrial fib or flutter, ectopy such as premature beats, or ventricular tachycardia). Holter monitor does not detect ischemia and is not accurate for evaluating the ST segment.

Question 27

How is nitroglycerin delivered in chronic angina? How is it delivered in acute coronary syndromes?

Answer 27

NG can be delivered orally or by transdermal patch in chronic angina. For acute coronary syndromes, NG is delivered in sublingual, paste, and IV form.

Question 28

When is clopidogrel used?

Answer 28

- Aspirin intolerance such as allergy | - Recent angioplasty with stenting

Question 29

For what 2 conditions are ACEI's/ARB's the DOC?

Answer 29

- Low EF / systolic dysfunction | - Regurgitant valvular disease

Question 30

For what 4 diseases, equivalent to CAD, should the goal of LDL be below 100, and for which statins should be used to bring down the LDL if above 100.

Answer 30

- Peripheral artery disease (PAD) - Carotid disease (not stroke) - Aortic disease (the artery, not valve) - Diabetes mellitus

Question 31

Wide splitting of S2 with a loud P2 or tricuspid and pulmonary valve insufficiency; dyspnea; syncope

Answer 31

Pulmonary HTN