Chest pain

Question 1

GI causes of acute onset chest pain

Answer 1

Eosophageal spasm
Pancreatitis
Cholecystitis

Question 2

Coronary spasm may occur secondary to which drug

Answer 2

Cocaine

Question 3

What infection can cause attacks of severe pain in the lower chest, often on one side. The slightest movement of the rib cage causes a sharp increase of pain,

Answer 3

This is bornholm disease- causes pain in the chest or upper tummy and flu-like symptoms. (usually affects children/young adults!)

There is inflammation of intercostal muscles due to Cocksackie B virus

Question 4

What are the clinical signs of hypercholesteralaemia and which of this is a normal finding in the elderly?

Answer 4

Signs of hypercholesterolaemia:

cholesterol deposits in small skin lumps
on the tendons of the back of the hand or bony prominences like elbows
(xanthomata),

in creamy spots around the eyes (xanthelasma), or a

creamy
ring around the cornea (arcus). Note that arcus is a normal finding in the
elderly

Question 5

Signs of systemic atherosclerotic disease

Answer 5

Signs of systemic atherosclerotic vascular disease: weak pulses, peripheral
cyanosis, atrophic skin, ulcers, bruits on auscultation of carotids.

Question 6

What is the relevance of AFs to ACS

Answer 6

AFs may exacerbate ACS. If there is AF on top of ACS, it will reduce cardiac output and might push the poorly perfused heart into ischaemia

AF may result from previous ischaemic damage and therefore might offer a clue of what is wrong with the patient

Question 7

Features of aortic dissection

Answer 7

Aortic dissection:
− History of sudden-onset tearing chest pain radiating to the back.

− Absent pulse in one arm.

− Hypertension (in about 50% of cases) or hypotension (in about 25% of cases).

− A difference in blood pressure between arms >20 mmHg (about a third of
cases).

− New-onset aortic regurgitation. This is caused by the new lumen tracking
down to the valve and making it incompetent.

− Pleural effusion, usually on the left. This is due to irritation of the pleura by
the dissecting aorta

Question 8

T/F pneumothoraces always comes with chest pain?

What type of chest pain does pneumothorax cause

Answer 8

F

History of sudden-onset pleuritic chest pain with breathlessness – but
beware, it may present as painless breathlessness.

Question 9

What happens to the chest wall, and what happens to the lung in a pneumothorax

How is this different to what happens with a collapsed lung

Answer 9

Normally lack of air in pleural space creates a vacuum that holds the lung to the chest wall.

When air disrupts this, the unopposed recoild of the chest wall will cause it to pop out, whilst at the same time the lungs will shrivel up.

Note this is diff erent from lung collapse, in which a bronchus is obstructed
and the air trapped distally in that segment is gradually absorbed into the
blood.)

Question 10

What is the management of a patient when the trachea is deviating away from a suspected pneumothorax?

Answer 10

a trachea that deviates away
from a suspected pneumothorax is an emergency requiring urgent insertion of a large-bore cannula in the mid-clavicular line just above the third
rib to allow the air trapped in the pleural space to escape

Question 11

Signs of a PE

Answer 11

− Signs of hypoxia. Th e patient may appear pale, have cold peripheries, feel
lethargic and/or be drowsy or confused, depending on the degree of hypoxia.
− Right heart strain evidenced by a raised jugular venous pressure (JVP)

Question 12

Features of booerhaave’s perforation

Answer 12

− History of sudden-onset severe chest pain immediately following an episode of vomiting. Shortness of breath and pleuritic pain may develop shortly afterwards due to subsequent pleurisy and eff usion

− Signs of a pleural effusion after some hours – dullness to percussion, absent
breath sounds, decreased vocal resonance.

− Subcutaneous emphysema is present in a minority of cases.

− Abdominal rigidity, sweating, fever, tachycardia, and hypotension may be
present as the illness progresses but are non-specific

Question 13

How often should you do ECG in someone presenting with acute chest pain

Answer 13

2 ECGs 30 minutes apart

Or if continuing chest pain, every 10-15 minutes until diagnosis made

If patient admitted, ECGs should be performed daily for 3 days after as changes might take 24hrs+ to develop.

Looking for signs of ischaemia and AF

Question 14

Signs of ischaemia on ECG

Answer 14

ST elevation, new onset LBBB

Pathological Q waves (old infarct)

Question 15

What are the advantages and drawbacks of troponin

Answer 15

+ve:

-Highly sensitive and specific for damage to cardiac muscle

Drawback:
-There is a MINIMUM 8 hour delay in increased troponin levels.`

Question 16

Alternative to troponin and the benefit of using it

Answer 16

. An alternative is CK-MB, an isotype
of the enzyme creatinine kinase, which is released more rapidly following damage but which is less specifi c for cardiac damage. CK-MB levels fall back to
normal within 2–3 days whereas troponin levels remain high for >7 days.

Question 17

What does it suggest if CK-MB levels are elevated >4 days after an MI

Answer 17

CK-MB levels that are elevated >4 days after an MI suggest that there has been a re-infarction

Question 18

T/F troponin is specific for ACS

Answer 18

F.

It IS specific for cardiac damage, but not 100% specific for ACS.

Question 19

What are the other causes of a raised troponin

Answer 19

Other
conditions causing a raised troponin include: coronary artery spasm (e.g. from
cocaine) or aortic dissection causing ischaemia, myopericarditis, severe heart
failure, cardiac trauma from surgery or road traffic accident, and PE.

Question 20

How does an MI affect cholesterol levels

Answer 20

An MI will result in a decrease in total cholesterol, low-density
lipoprotein (LDL), and high-density lipoprotein (HDL) within about 24 hours
of the infarct, and that levels will not return to normal (for that patient) for
2–3 months post-infarct.

Thus, cholesterol levels should be measured as soon
as possible if they are to guide future therapy.

Question 21

What will a chest radiograph typically show with a boerhaave’s perforation

Answer 21

If Boerhaave’s perforation of the oesophagus is suspected, a chest radiograph will typically show air around
the heart shadow (pneumomediastinum), a pleural effusion, and/or a pneumothorax

Question 22

What drug should you not give to somebody who is having an MI

What should you give

Answer 22

Warfarin (it initially causes clotting by initial inhibition of protein C and S)

You should give LMWH heparin

Question 23

STEMI management medication do you give to STEMI FIRST

Answer 23

300mg loading dose of aspirin then 75mg maintenance.

If it’s less than 12 hrs since onset then straight to cath lab for PCI

If it’s greater than 12 hrs then you do angiography then PCI cath lab

Question 24

NSTEMI management

Answer 24

300mg loading dose of aspirin then 75mg maintenance.

Give then fondaparinux and LMWH

Question 25

Complications of ACS

Answer 25

Death 
Arrhythmia 
Rupture (of papillary muscle) 
Tamponade 
Heart failure 

Valve disease 
Aneurysm
Dressler's syndrome
Embolism
Re-infarction

Question 26

Patient presents with following

• Raised JVP
• Muffled heart sound
• Low BP

What position relieves it

What ECG change is likely

Answer 26

Pericarditis!

Diffuse saddle shaped ST elevation!

Sitting forward relieves

Question 27

What scoring system is used for post NSTEMI risk of death

Answer 27

GRACE

Question 28

What is LVH on ECG

Answer 28

QRS greater than 7 squares. HTN

Question 29

Respiratory causes of AF

Answer 29

PE, pneumonia

Question 30

5 causes of pleuritic chest pain

Answer 30

5Ps: 
PE
Pneumothorax
Pericarditis
Pleurisy 
Pneumonia 

Subphrenic pathology (abscess), rib fractures and costochondritis