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Primary care of adults 2 > Chest Pain (7 questions) > Flashcards

Chest Pain (7 questions) Flashcards

1
Q

Common causes of ischemic CV pain

A
  • ACS > NonSTEMI, unstable angina, STEMI
  • Angina
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2
Q

Common causes of nonischemic CV chest pain

A

Systemic HTN, AV regurg, AS, arrhythmias, pericarditis, aortic dissection, MVP

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3
Q

Where may chest pain originate other than the heart?

A

Pulmonary, GI, Musculoskeletal, Psychogenic, Neuropathic…

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4
Q

Examples of pulmonary chest pain

A

PE, PHTN, pneumothorax, pleuritis, pneumonia

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5
Q

Causes of GI chest pain

A

GERD, esophageal rupture, PUD, esophageal spasm, pancreatitis, biliary dz

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6
Q

Causes of Musculoskeletal chest pain

A

costochondritis, Tietze syndrome, Rib fracture, cervical disc

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7
Q

Causes of psychogenic chest pain

A

panic do

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8
Q

causes of neuropathic chest pain

A

HZ

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9
Q

Describe common characteristics of ischemic chest pain

A
  • typically deep pain: retrosternal or substernal and felt across both sides of the chest and down the medial aspect of the left arm
  • described as: pressure, tightness, crushing, squeezing, aching
  • Radiating below the diaphragm and above the mandible?? →Rarely ischemic
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10
Q

What would you see on an EKG for ischemic chest pain?

A
  • may show
    • ST elevation, depression (downsloping or horizontal appearing) or T wave inversions.
  • Changes may not be present in some cases
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11
Q

Describe common characteristics of angina:

how, when, where, duration, assoc sx

A
  • “Strangling of the chest”
  • Transient episodes of sub-sternal CP
  • Associated with exertion & emotional distress
    • Especially with hurrying, walking on an incline, walking in cold or windy weather
  • May be accompanied by:
    • Arm, jaw, back, neck pain
    • Nausea, vomiting. dyspnea, diaphoresis can occur
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12
Q

What relieves angina?

A
  • Relieved with rest or NTG
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13
Q

Is angina located in the middle or lower abdominal region?

A

no

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14
Q

Can anginal pain be localized by one finger?

A

no

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15
Q

Is angina a constant pain that lasts many hours or fleeting pain that lasts a few seconds or less?

A

neither

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16
Q

Does anginal pain radiate to lower extremities?

A

no

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17
Q

What is vasospastic angina?

A
  • Also called Printzmetal’s Angina or Variant Angina
  • Pain similar to classic angina but onset at rest
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18
Q

conditions assoc w/vasospastic angina

A
  • 25% also have migraines and Raynauds
  • More common with heavy smokers
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19
Q

What testing may be done to confirm vasospastic angina?

A
  • ST elevation on EKG
  • Spasm provoking testing done during cardiac cath
  • Mixed angina is possible-combination of classic and spastic; Atheromas may encourage spasm
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20
Q

What would be Rxed for vasospastic angina?

A

Ca channel blockers and nitrates may be indicated for spasm

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21
Q

What are “anginal equivalents”?

A

A symptom representing angina which is not chest pain/discomfort

  • Nausea, vomiting, diaphoresis, DOE, or fatigue
  • In diabetic or the elderly: fatigue, epigastric discomfort, DOE, palpitations, lightheadedness
  • Dyspnea is the most common anginal equivalent
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22
Q

Common symtpoms of MI and unstable angina?

A
  • CP: pressure, squeezing, fullness, aching burning, heaviness
  • Radiation to the jaw, neck, arms, teeth
  • With SOB, nausea, diaphoresis, lightheadedness
  • Pain waxes and wanes, lasts more than 15 minutes
  • USA pain may occur with little exertion or at rest
  • Stable disease is now unstable
  • Pain with decreased workloads is concerning
  • Rest pain is very concerning and requires admission
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23
Q

What are some less typical Sx of ACS?

A
  • Pain in area other than chest
  • Numbness, tingling, stabbing, burning
  • No chest pain
  • Indigestion
  • Lightheadedness
  • Fatigue
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24
Q

Women: symptoms of ACS

A

nausea, lightheadedness, unusual fatigue, upper back pain

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25
Q

Elderly: sx of ACS

A

dyspnea, mild Sx, vague report, no CP

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26
Q

Diabetes: Sx of ACS

A

weakness, dyspnea, nausea, palpitations, no CP

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27
Q

What are some biomarkers of acute MI?

A

CK - total and MB

Troponin

Myoglobin

Lactate dehydrogenase

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28
Q

How long does troponin stay around?

A

up to 10 days

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29
Q

What is/ causes pericarditis?

A
  • Inflammation of the pericardial sac
  • Commonly caused by viral, bacterial or fungal infections, trauma, surgery, MI
  • Also caused by neoplasms (breast and lung Ca and lymphoma- more commonly), radiation, uremia (RF), post cardiac surgery, autoimuune diseases, antiphospholipid syndrome
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30
Q

Pericarditis: gender and age groups

A

Incidence higher in males
Ages 20-50

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31
Q

Characteristics of the pain of pericarditis

A
  • Pericarditis pain waxes and wanes over hours to days (can last 30 mins or more at a time)
  • Pain: sharp, piercing, localized discomfort in the retrosternal area and left precordium radiating to the back and left shoulder
  • CP exacerbated by deep inspiration, cough, lying down and improves when sitting up and leaning forward
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32
Q

Pericarditis Sx (in addition to pain)

A

Sx: Dyspnea, cough, chills, weakness
Fever may be present

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33
Q

What does / does not relieve the pain of pericarditis?

A

Pain occurs suddenly & is unrelieved with nitrates, relieved by sitting forward

NOT relieved by rest

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34
Q

When might pericarditis occur in relation to an MI?

A
  • Can occur 2-4 days post MI
  • Dressler’s syndrome can occur 3 weeks to several months post AMI (injury to heart muscle that causes blood in pericardium → pericarditis)
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35
Q

What medications can cause pericarditis / lupus like Syndrome?

A

pronestyl, cardizem, INH, apresoline. Collagen Diseases: SLE and RA can develop pericarditis

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36
Q

Findings associated with pericarditis

A
  • ST segment elevation on EKG (diffuse-most leads except V1 and AVR)
  • Physical Findings: pericardial friction rub (left lower sternal border 4-5 ICS)

Position patient: lean forward and exhale

  • Jugular vein distends on inspiration when the patient is sitting at a 45 degree angle
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37
Q

Complications of pericarditis

A

Tamponade (hypotension, JVD, muffled heart sounds)

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38
Q

EKG changes associated with pericarditis over time

A
  • Day 2-3 and up to 2 weeks: Diffuse ST elevation. PR seg. depression II, V4-6
  • Days-several weeks: ST segment at baseline with flat T waves
  • 2-3weeks-several weeks: T wave inversion
  • Weeks-up to 3 months: Gradual resolution of T waves
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39
Q

Tests ordered in pericarditis

A
  • CXR
  • EKG
  • Echocardiogram
  • Labs
    • ESR
    • CBC
    • LFTs
    • PT/PTT
    • CPK/Troponin
    • Possibly: ANA, RF, TB screening, HIV
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40
Q

Sx of Pulmonary Embolus

A
  • Sudden onset pleuritic CP, SOB, may have hypoxia
  • Other symptoms: cough, hemoptysis (30%), dyspnea, or no symptoms at all
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41
Q

Risk factors for pulmonary embolus?

A

pelvic or leg trauma, neoplastic disease, travel, immobility, recent surgery, obesity, hypercoagulable states, oral contraception, cigarette smoking

42
Q

Clinical manifestations of pulmonary embolus

A
  • 60% of people have a HR >100, 85% have rapid respirations >20/min
  • EKG: ST depression II, III, F, V2, V3, inverted T waves but there may be no changes
43
Q

Tx for Pulmonary Embolus

A

anticoagulation

44
Q

Diagnostic tools in PE

A
  • CXR
  • Compression venous U/S of the legs (Duplex Doppler Ultrasound)
  • ECG
    • ST and T wave changes 70% of pts
  • ABGs
  • D-Dimer test
    • Measure of fibrin levels
    • Sensitivity 85-100%
    • Specificity 40-68%
  • Ventilation/Perfusion Scan (V/Q scan) - MOST LIKELY or
  • Helical Cat Scan (Spiral CAT Scan) - MOST LIKELY
  • Pulmonary Angiography - GOLD STANDARD
45
Q

Sx of aortic dissection

A
  • Pain is usually persistent, severe, ripping, tearing, knife-like
  • May be felt in the chest or back
  • Pain may migrate following the path of dissection—Chest, back, flank
  • Dissection pain is prolonged but stops when the dissection is complete
46
Q

Risk factors for aortic dissection

A

history of HTN, Marfans syndrome, bicuspid aortic valve, atherosclerosis, aortic surgery, known aneurysm

47
Q

What causes the pain of aortic dissection?

A

Pain is due to compression of the adjacent structures or vessels, or a thromboembolic event

48
Q

Possible complication of aortic dissection

A

Myocardial ischemia/infarct can occur due to aortic compression by dissection or hematoma. The RCA is commonly involved

49
Q

Testing done in suspected aortic dissection

A

CT scan, arteriogram, ultrasound

50
Q

Tx aortic dissection

A

Emergency Surgery

51
Q

Sx of pneumothorax

A
  • Sudden onset of substernal pain located to right or left chest at rest (ipsilateral side)
  • Radiates widely to right or left chest
  • Pain in arms, shoulder, back
  • Increases with deep inspiration
  • Changes to dull, steady ache over time
  • SOB at rest
  • Tachycardia, tachypnea
52
Q

Risks for pneumo

A

More common with COPD, cigarette smoker

53
Q

Diagnostic tests for pneumo

A

CXR

54
Q

Sx of MVP

A

intermittent sharp or tugging left sided CP without radiation

Other symptoms may include: fatigue, SOB, orthopnea, syncope, palpitations

55
Q

MVP: relationship with exertion

A

none

56
Q

Risks for MVP

A

Common in people who are lean, thin and may have skeletal abnormalities, i.e. Marfan syndrome, or pectus excavatum, scoliosis

more common in women

57
Q

MVP: what you may find on PE

A

Midsystolic click at apex with mid-late systolic murmur-may be intermittent

58
Q

Dx tests for MVP

A

echocardiogram

59
Q

Endocarditis: causitive agents

A

1) S. Aureus
2) Strep Viridans

60
Q

Endocarditis: risk factors

A

IV Drug Abusers, central lines, prior valve replacement/valvular surgery, recent dental surgery, weak valves

(more males, kids, elderly)

61
Q

Sx of endocarditis

A

Fever, diaphoresis, chills, aches & pains; splinter hemorrhages

62
Q

Diagnostic tests for endocarditis

A
  • Blood cx
  • CBC
  • CRP
  • ESR
  • Urine
  • EKG
  • Echo
  • TEE
63
Q

Tx for endocarditis

A
  • Long term IV antibiotics
  • Supportive care
  • Valvular repair
64
Q

Secondary complications of endocarditis

A
  • Thrombi
  • CHF
  • CVA/TIA
  • Glomerulonephritis
65
Q

What prophylaxis would be given for endocarditis before dental work?

A

Amoxicillin 2g 1 hr before procedure

Ampicillin, ceftriaxone for IV.

66
Q

What 4 groups should receive prophylactic antibiotics?

A
  1. pts w/ prosthetic valves
  2. pts w prior IE
  3. cardiac transplant w valulopathy
  4. certain congenital HD
    1. includes shunts, conduits, w/I 6 months of cardiac transplant (post 6 months don’t need abx)
  • Pts w MVP (w or w/o regurg) NO LONGER need prophy
67
Q

What types of procedures warrant prophylactic antibiotics?

A
  1. If involve manipulation/perforation of oral mucosa
  2. Respiratory surgery involving incisions or biopsy of respiratory mucosa (tonsillectomy)
  3. DO NOT need for GI/GU procedure.
68
Q

Sx of aortic stenosis

A
  • Can range from Mild to Severe
  • Substernal pain which may radiate to the jaw, arms, neck.
  • Can have a dramatic presentation: syncope
69
Q

What causes the pain associated with AS?

A

Ischemic pain!

Thickened heart muscle needs more O2 to pump, but decreased cardiac output so not getting it

70
Q

Clinical signs of AS?

A

May have a systolic ejection murmur radiating to neck

71
Q

Diagnostics for AS

A
  • Diagnostics: Echocardiogram, cardiac cath
  • Cardiology consult prior to any consideration of stress test (syncope)
72
Q

Sx of GERD chest pain

A
  • Substernal CP radiates to arms ,back, neck, jaw
  • Pain occurs 20-30 minutes after meals
  • Pain may last for several hours
  • Exacerbated by lying down, nocturnal, bending
  • Burning in throat or bad taste in mouth
73
Q

What meds aggravate / alleviate GERD?

A
  • Relieved with antacids, belching
  • Worse with NTG or Ca channel blockers
74
Q

Diagnostics for GERD

A

radiologic testing, endoscopy-EGD

(esophagogastroduodenoscopy)

75
Q

Tx of GERD

A

antacids, PPI or H2 blockers

76
Q

Sx of biliary dz

A
  • Pain radiates to the chest, upper back, shoulder(s)
  • Usually occurs after high fat meals
  • May be accompanied by nausea and vomiting, fever
  • May also have right upper quadrant pain which may be described as sharp pain
  • Patient may be very uncomfortable during an acute episode
  • Not related to exertion
    *
77
Q

Diagnostics for Biliary Dz

A

Labwork, U/S, HIDA scan may confirm GB disease

78
Q

Risk factors for biliary dz

A

5 Fs- Fat, Fair, Female, Forty, Fertile

79
Q

Sx of costochondritis/chest wall pain

A
  • Superficial localized or pain at one or more of the costrochondral junctions, one or more of which may be tender to touch or with movement: Point tenderness; no swelling
  • May have a sudden or gradual onset
  • Worse with deep breath ; or movement of the shoulder girdle
  • Common cause of CP for ages 10-21 yrs (up to 40)
  • Occasionally find Tietze’s syndrome: + swelling, erythema or warmth at the junction
80
Q

Tx of costochondritis/chest wall pain

A

NSAIDS, moist heat, rest

81
Q

Sx of chest muscle spasm

A
  • Sudden onset of sharp grabbing pain in the anterior chest, often on the left side
  • Lasts < 3 minutes
  • Resolves spontaneously
  • May also intensify with breathing
82
Q

Diagnostics for chest muscle spasm

A

history, PE

83
Q

Characteristics of postcardiotomy pain

A
  • Post chest surgery pain
  • Chest pain, shoulders, upper back
  • Increase with movement, palpation
  • Sharp, fleeting nonexertional CP
  • Zapping nerve like pain-particularly in right or left upper chest (LIMA, RIMA)
84
Q

Questions to ask if suspect postcardiotomy pain

A

Determine date of surgery
Onset of pain-does it coincide with surgical intervention?

85
Q

Diagnostics for postcardiotomy pain

A

PE

86
Q

Sx of herpes zoster pain

A
  • Sharp, stabbing pain on one side of the chest
  • Pain prior to the vesicles up to 48 hours
  • Herpetic vesicles along the dermatome
  • Doesn’t cross the midline
87
Q

Diagnostics for HZ

A

PE

88
Q

Tx of HZ

A

Acyclovir, neurontin, pain medication

89
Q

Sx of pleuritis

A
  • Fairly localized stabbing, sharp, shooting pain
  • Worsening pain with deep inspiration: pleuritis
  • Concurrent or preceeded by: respiratory infection, pneumonia, pneumothorax, PE, malignancy, collagen disease
  • Rub may be heard with lung auscultation
90
Q

Tx pleuritis

A

Treat underlying cause, pain medication

91
Q

Sx asthma

A
  • Feeling of chest constriction
  • Anxiety, cough, wheeze, poor air exchange
  • Dypsnea
  • Associated with infection, chemical triggers, allergies, stress
  • Fam Hx of allergy/asthma/eczema; Aspirin allergy
92
Q

Asthma tx/mgmt

A

Relieved by nebulized albuterol, steroids, antibiotics if indicated and other medication

93
Q

Sx of pneumonia

A
  • Pain may or may not be present
  • Gradual onset
  • May be referred to abdomen
  • Fever
  • Cough: may be non-productive at first
  • Fatigue
  • Adventitious breath sounds
94
Q

Diagnostics for pneumonia

A

CXR, WBC count

95
Q

Tx of pneumonia

A

Antibiotics-bacterial; otherwise supportive care

96
Q

Cause of chest pain associated w/palpitations

A
  • May result from ischemic and nonischemic process
  • Patients can feel palpitations with any heart rhythm
  • Sinus tachycardia increases MVO2 and can cause CP in those with CAD, AS, cardiomyopathy
97
Q

Diagnostics fo palpitations

A

Holter, event monitor, EKG, echo, possible stress test

98
Q

Rx for palpitations

A

maybe BBs

99
Q

How do you make the dx of chest pain d/t panic d/o?

A

R/O other causes

100
Q

Tx of CP d/t Panic Do

A

treatment for anxiety

101
Q

What to do if CP of CV origin?

A

EKG, monitor

Remember MONA?

  • Morphine
  • Oxygen(2-4L NP nasal prongs?)
  • Nitrates (none for AS)
  • Aspirin (ASA 4-81mg or 1-325mg)
102
Q

Nitrates and aortic stenosis

A

may cause severe hypotension in AS!

any drug that causes hypotension should be used with caution or not at all

Primary care of adults 2 (15 decks)

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