Chest pain Flashcards
Differentials of chest pain
1) Cardiac (MI, pericarditis, aortic stenosis)
2) GI (gastritis/ulcer secondary to naproxen, GI bleed, GORD, oesophageal malignancy, pancreatitis, biliary colic)
3) Respiratory (PE, pleurisy, pneumonia, lung cancer)
4) MSK (muscular, shingles, costochondritis, aortic stenosis, se statins)
5) Vascular (dissecting aneurysm)
Differentials of swollen ankle
1) Cellulitis
2) Oedema
3) Osteoarthritis/lymphoedema
4) Fracture
5) Gout
6) Inflammatory arthritis
7) Septic arthritis
8) DVT
Differentiating hx of cellulititis
Red, hot ankle, fever, ankle joint movable
Differentiating hx of oedema
Pitting
Differentiating hx of osteoarthritis/lymphoedema
No pitting, no trauma
Differentiating hx of fracture
Evidence of trauma
Differentiating hx of gout
Red, hot ankle, no fever, no swollen calf, no pain in other joints
Differentiating hx of inflammatory arthritis
Red, hot ankle, no fever, no swollen calf, pain in multiple joints
Differentiating hx of septic arthritis
Red, hot ankle, fever, ankle joint unmovable
Differentiating hx of DVT
Red, hot ankle, no fever, swollen calf
What should be taken into account when prescribing NSAIDs?
When prescribing an NSAID, individual risk factors for adverse effects should be taken into account and include any contraindications, drug interactions, medical history, and any monitoring requirements.
Can people with heart failure take NSAIDs.
Yes depending on the severity of the heart failure.
• Severe heart failure — NSAIDs should be avoided.
• Mild, moderate, or severe heart failure — COX-2 inhibitors, diclofenac, and high-dose ibuprofen (2400 mg or more daily) should be avoided.
• Mild to moderate heart failure — a standard NSAID should be prescribed (but not diclofenac or high-dose ibuprofen), and the person should be monitored closely.
• Ibuprofen up to 1200 mg daily, or naproxen up to 1000 mg daily, should be first-line options.
Can people with CVD take NSAIDs?
Yes.
For people with ischaemic heart disease, cerebrovascular disease, or peripheral arterial disease, ibuprofen up to 1200 mg per day or naproxen up to 1000 mg daily, should be first-line options.
Which NSAIDs are CI in people with CVD?
COX-2 inhibitors, diclofenac, and high-dose ibuprofen are contraindicated.
Can people with renal impairment take NSAIDs?
No but if used, they should be monitored closely.
For people with severe renal impairment (estimated glomerular filtration rate [eGFR] less than 30 mL/minute/1.73 m2), ideally NSAIDs should be avoided.
If an NSAID is used, the person should be monitored closely.
What should a doctor do to prevent GI adverse effects associated with NSAIDs?
- An alternative analgesic should be considered.
- Prescribing more than one NSAID at a time should be avoided.
- Concomitant use of an NSAID with low-dose aspirin should be avoided
- Short-acting NSAIDs (such as ibuprofen) should be used in preference to long-acting formulations (such as naproxen).
WHat can be done for people at risk of GI adverse events with NSAIDs?
- High risk of GI adverse events — a COX-2 inhibitor should be prescribed with a proton pump inhibitor (PPI).
- Moderate risk of GI adverse events — a COX-2 inhibitor should be prescribed alone, or an NSAID plus a PPI.
- Low risk of GI events — a non-selective NSAID should be prescribed.
What is the problem with taking SSRIs and NSAIDs?
Selective serotonin uptake inhibitor (SSRI) itself can increase the risk of bleeding, particularly within the GI tract when combined with an NSAID.
What advice should be given to a patient on NSAIDs and SSRIs?
The risk of bleeding should still be communicated to the patient; he should be advised not to suddenly stop his antidepressant, but to report any indigestion or stomach upset.
PPI should be prescribed as well
What is a significant event?
1) A significant event (also known as an untoward or critical incident) is any unintended or unexpected event, which could or did lead to harm of one or more patients.
2) This includes incidents which did not cause harm but could have done, or where the event should have been prevented.
What is a cognitive bias?
1) Cognitive bias is an error in thinking, reasoning or evaluating, which in medicine can lead to the wrong diagnosis for a patient.
What is anchoring bias?
Anchoring bias is a form of bias where an individual depends too heavily on an initial piece of information. For example, when patients are repetitively clerked in hospital, we often refer to the initial diagnosis without questioning and checking.
What is availability bias?
The tendency to let an example that comes to mind easily (because you have recently seen or been taught about it, or you had a particularly vivid experience of the case) affect your decision making or reasoning.
What are the three common causes of epigastric pain?
MI, pancreatitis and gastric erosions.
