Chest Pain Flashcards
Common and concerning symptoms related to chest pain
. Shortness of breath . Exertional complaints . Palpitations . Fainting/near fainting spell . Edema . Orthopnea . Hemoptysis
Pleura components
. Visceral/parietal pleura
. Pleural space
Pleuritic pain
. Pain w/ deep breathing
. Many conditions related w/ this
Important questions to ask w/ chest pain
. What kind of pain . Quality of pain . Severity . Any radiation . Any prior episodes . Any assoc. symptoms . Any exertional symptoms
How to create differential diagnosis
. Detailed past medical/surgery/family history . Medications . Social history . Understanding of patient’s complaint . OB/GYN history and pregnancy . Life style choices . Recent travel
Reasons chest pain is diaphragm
. Water pus, or blood in diaphragm
. From injury, infection, TB, cancer, ectopic pregnancy
What ethnicity is higher risk for MI
Asian women because of small coronaries
Differential diagnoses for chest pain
. Angina: pain related to cardiac disease . MI . PE . Pericarditis: inflammation of pericardial sac . Aortic dissection . Shingles . Musculoskeletal . GERD . Pneumothorax . Panic disorder
Systole
. Ventricles contract raises pressure . A/V valves close making S1 . Pressure continues to inc. . Aorticpulmonic valves open . Blood ejected into arteries
Diastole
. Aortic/pulmonic valves close (S2) . A/V valves open . Blood moves from atria to ventricles . Atria contract as ventricles almost filled . Causes complete emptying of atria
Aortic post
R 2nd intercostal space (R upper sternal border)
Pyloric post
L 2nd intercostal space
. Left supper sternal post
Tricuspid
L lower sternal border
4th intercostal on left
Mitral valve
L 5th intercostal space
. Midclavicular
Grades of murmur
1: Faint, barely audible
2: soft, but audible
3: moderately loud
4: loud w/ assoc. thrill
5: very loud and thrilling, audible w/ diaphragm on end
6: very loud, thrill, audible w/ stethoscope off Chest
Innocent murmur
. Err less sound made by blood circulating in heart . In children . Short and soft, grade 2 or less . Systolic ejection murmur . Normal S1-2 . Normal cardiac impulse . No hemodynamic abnormality
Split S2
. Physiological split S2
. Natural delay in closure of pulmonic valve
. Inc. venous return to right side of heart delays closure
Midsystolic murmur causes
. Aortic stenosis
. Pulmonary stenosis
. Atrial septal defect
. HOCM
Holosystolic murmur cause
. Mitral regurgitation
. Tricuspid regurgitation
. Vid
Late systolic murmur cause
Mitral valve prolapse
Early diastolic murmur causes
. Aortic regurgitation
. Pulmonic regurgitation
. Austin-Flint
Mid/late diastolic murmur causes
. Sitral stenosis
. Tricuspid stenosis
Rare murmur cause
Patent ductus arteriosus
ECG
. Records depolarization/depolarization
. Doesn’t record contraction of heart
. P-wave spread of stimulus through the atria
. PR interval: time from stimulus of atria to stimulation of ventricle
. QRS complex: depolarization of ventricle, depolarization of atria (not visible)
. ST segment/T wave: return of stimulated ventricular muscle to resting state (ventricular repolarization)
. TP segment: ventricles depolarizer, ready for next depolarization, used as baseline to compare for ST elevation/depression, PR depression
1stt type AV block
. PR interval long (>200 ms)
. Each big box is 200ms/0.2s
2nd type I AV block
. PR gets longer and longer then loses a beat
. Regularly irregular
2nd type II AV block
. PR normal
. Lose a beat
3rd type V block
. P waves and QRS independent of each other
Tachycardia
. A fib: QRS not spaced out equally, no discernible P waves
. A flutter: saw tooth pattern
. Supraventricular tachycardia (AVNRT, AVRT, WPW)
. Ventricular tachycardia, fibrillation, tornados de pointes
MI
. Blockage of 1 of the vessels feeding the heart
. Chest pain, diaphoresis, dyspnea
. Risk factors: hypertension, hyperlipidemia, DM, smoking, alcohol, stress
. EKG shows ST elevation
Troponin vs CKMB
. Troponin most sensitive, much higher levels released in MI
. CKMB: in cardiac tissue, good test only if skeletal muscle isn’t damaged, lower concentration available for less amount of time
PVC
Premature ventricular contraction
QRS>0.12, very larger and widened
PAC
Premature atria contraction
Contains P-wave from atria
. QRS <0.12
. Very short
Most common EKG finding in in PTE
Sinus tachycardia
PTE risk factors
. Recent trauma . Surgery . Travel . Obesity/sedentary lifestyle . Cancer
D-dimer
. Fibrin degradation product . Signifies that clot was formed recently . Has great negative predictive value . Non-specific if positive . Good to rule out DVT/PE
Aortic dissection
. Tear in innner layer of aorta
. Blood pools in wall
. Obstructs arteries feeding the brain causing syncope
. Symptoms: crushing chest pain radiating to back
. Can cause tachycardia, hypotension, dec. perfusion to kidneys
GERD improves w/ ___
. Antacids
. H2 blockers
. Proton pump inhibitors
Costochondritis
. Inflammation of sternocostal joints
. Caused by viral URI, excessive coughing, minor trauma
. Chest pain/tenderness to palpation of sternum/ribs
. Improves w/ anti-inflammatories
Herpes zoster treatments
. Acyclovir, valacyclovir, narcotics
massive PE
Hypotension and shock are markers
Clot so big it affects the heart
Right sided murmurs will increase with ____
Inspiration
Guide to murmur diagnosing
. Systolic or diastolic . L/R sided in origin . Characteristics (crescendo, holosystolic) . Location . Radiation
Systolic murmur and causes
. Swooshing sound
. Occur right after S1 (closing of mitral) and before S2 (closing of aortic)
. Aortic stenosis, mitral regurgitation, VSD (hole in interventricular septum and blood crosses to high pressure side to low pressure side)
Mitral regurgitation
. Incompetent valve
. Abnormal leaking of blood from LV into LR
. Causes: myxomatous degeneration, MI, dilated LV
. Sounds holosystolic that radiates to axilla
Tricuspid regurgitation
. Incompetent valve
. Abnormal leaking of blood from RV to RA
. Causes: myxomatous degeneration, inc. R sided pressures
. Sounds: holosystolic, inc. w/ inspiration, no radiation
VSD
. Congenital hole in septum
. L heart pressure high than right
. In systole, heart contracts and blood in left goes across into right side
. Sounds: holosystolic like mitral, over sternal border
Aortic stenosis
. Valve narrows creating turbulent flow
. Result: heart has to work hard by creating pressure to get blood across stenotic valve
. Causes: congenitally bicuspid valve, wear and tear from age, rheumatic fever
. Sound: crescendo-decrescendo murmur in systole, radiates to carotid
T/F diastolic murmurs are always pathologic
T
Diastolic murmurs
. Swoosh right after S2 and before S1
. Blood having trouble leaving atrium to ventricle because mitral stenosis
. Aortic regurgitation
Aortic regurgitation
. Valve doesn’t close
. Blood comes back into heart
. Causes: congenitally bicuspid valve, rheumatic disease
. Sounds: turbulence in diastole after S2, upper sternal and radiates inf.
. Best heard w/ patient sitting up and leaning forward in expiration
Austin flint murmur
. Vibration of ant. Leaflet of mitral valve as it is buffetted simultaneously by blood jets from LA and aorta
Mitral stenosis
. Blood can’t get out of L atrium
. Occurs when valve is less than 2 cm wide
. Causes pressure gradient across valve and turbulence
. Causes: rheumatic heart disease, damage from endocarditis
. Sounds: mid-diastolic rumbling murmur will be heard after opening snap, best heard in apical region, doesn’t radiate
PR interval
. Time from stimulus of atria to stimulation of ventricle (0.12-0.2 s)
QRS complex
Spread fo stimulus through ventricle
Hypertrophic cardiomyopathy
Hypertrophic ventricular septum on side of LV
. Gets louder w/ valsalva (standing)
. Due to genetic predisposition
Fixed split S2 (ASD)
. Inc. pulmonary blood flow from inc. preload from L to R shunt of blood across ASD delays closure of pulmonic valve
. Split doesn’t change w/ respiration
. ASD more hemodynamically significant than small inc. in volume of blood that results from inspiration
Pericardial rub
. Means pericarditis from recent upper resp. Tract infection (chest pain better w/ leaning forward and worse w/ lying down)
. Velcro sound that you hear throughout cardiac cycle
Sinus arrhythmia
. Time difference btw P-waves is highly variable
What Standing or valsalva test does to heart
. Decreases venous return (dec. preload)
What does hand grip test do to heart?
. Inc vascular resistance (inc. preload and afterload)
What does squatting test do to heart?
. Inc. afterload
. Highly inc. preload
Aortic stenosis murmur volume standing, hand grip, and squatting tests
. Standing: dec
. Hand grip: dec.
. Squatting: inc.
hypertrophic cardiomyopathy (HOCM) murmur volume standing, hand grip, and squatting test results
. Standing inc.
. Hand grip dec.
. Squatting dec.
mitral valve prolapse (MVP) murmur volume standing, hand grip, and squatting test results
. Standing inc.
. Hand grip dec.
. Squatting dec.
What murmurs get louder w/ valsalva
HOCM and MVP
