Chest Pain JOHNSTON

Question 1

What are some differential diagnoses for chest pain (non-AMI)?

Answer 1

1. GERD
2. Ischemic heart disease
3. chest wall syndromes (chondritis)
4. pericarditis
5. pleuritis
6. PE
7. Lung cancer
8. AA
9. AS
10. HZV

Question 2

What are the seven potentially lethal causes of chest pain? What are salient features of each?

Answer 2

1. Myocardial ischemia-
   - squeezing, Hx of risk factors, diaphoresis, palor, S4/S3
   - serial
2. AMI (NSTEMI or STEMI)
3. Aortic dissection
   - “tearing” btw scapulae, Hx HBP/marfan, AI, weak peripheral pulses
4. PE
   - cough hemoptysis, Hx surgery or immobilization, tachypnea
5. Pneumothorax (tension)
   - pleuritic pain, Hx chest trauma, hyper resonant chest sounds
6. Esophageal rupture
   - epigastric pain and vomiting, audible crepitus, hematemesis
7. pericarditis (effusion/tamponade)
   - crushing pain relieved by sitting forward, friction rub heard

Question 3

Unstable versus Stable Angina? How to treat?

Answer 3

Stable: pain/squeezing/pressure upon EXERTION, relieved by NITRO and REST. Some ST elevation or depression.
TX: diet, NTG, Nitrates, CCB, BB, Aspirin, ACEI
Unstable: WORSENING chest pain even at REST fro ore than 15-20mins, requires more meds, increased tempo, Atherosclerotic plaque rupture
TX: platelet antagonist, ACEI, NTG, hospital visit

Question 4

What are some lab tests for chest pain?

Answer 4

CBC- WBC, Troponin I, CKMB elevated with STEMI
CMP- monitor electrolytes
BNP- increased in HF (fluid overload)
CRP- elevated
Lipids- elevated

Question 5

What are some PE tests that can be done?

Answer 5

Treadmill Exercise Test, stress echocardiogram (wall, valve function), vasodilator nuclear perfusion and dobutamine nuclear perfusion

Question 6

What are some imaging that can be done?

Answer 6

CXR, echocardiogram, cardiac MRI