Chest Pain presentation Flashcards
What is the diagnosis if you have ST elevation on an ECG
STEMI
What is the diagnosis for chest pain if
- they have CV risk factors
- ischaemic ECG
- increased TnT
ACS
What is the likely diagnosis for chest pain if
-they have CV risk factors
-may have ST elevation
-sudden onset tearing chest, back pain, between shoulder blades, SOB, syncope
-diff BP in arms
-low BP
aortic murmur
What would you see on the CXR
What are the risk factors
Aortic dissection
-separation of intima and medial layers
CXR
-wide mediastinum
Risk factors
- male, age
- HTN
- aortic aneurysm
- connective tissue disorder
- bicuspid AV
What is the likely diagnosis for chest pain if
- they have central pleuritic pain on inspiration, orthopnea
- febrile
- risk factors
- global saddle ST elevation
- TnT not abnormally raised
What would you see on the CXR
What are the risk factors
Pericarditis
CXR
- wide mediastinum
- flask shape heart
Risk factors
- past viral infection
- male
- AI
What is the likely diagnosis for chest pain if
- they have sharp pleuritic pain on inspiration
- risk factors
- no ST elevation
What are your other differentials
What are the risks for this diagnosis
What are the symptoms
How would you diagnose/manage this
PE, but not always painful
Could be pneumothorax or pneumonia
Risks
- bedbound
- recent surgery/chemo
Symptoms
- calf swelling (DVT)
- SOB, tachypnoea
Diagnosis
- D dimer
- CTPA/ultrasound VQ
Management
-anticoagulants
What is the likely diagnosis if
- there is no ST elevation
- no Tnt changes
- central epigastric pain
What are the risk factors
What key symptoms would you see
What would the CXR show
How would you manage this
GERD
Risks
- NSAIDs
- spicy foods
Symptoms
-burning pain
ECG, CXR
-NAD
Management
- Alt pain relief
- omeprazole
What do you need to consider in a diabetic patient
Neuropathy => blunted pain response
How would you differentiate between typical, atypical and non anginal pain
Precipitated by physical exertion? Constricting comfort in ant chest, neck, shoulders, jaws, arms? Relieved by rest or GTN within 5mins? -GI causes can also be relieved by GTN -Time is subjective
What are the problems when asking about the quality of pain?
Score is based on patient perception
-more likely to be useful if they’ve had this pain before
Barriers to quality of assessment (difference between pain and discomfort) -gender, age -cultural perception -diabetes TAKE OTHER FACTORS INTO CONSIDERATION
How would you assess the severity of pain
Is this linked to past episodes?
Associated symptoms
-SOB, palpitations
-LOC, N+V
Duration
-lasts for seconds or for days => unlikely to be cardiac in origin
Why is ascertaining the timing of the pain important
What are the important features you want to get from a history
When did the pain first start, frequency of pain
Gradual or sudden?
Diagnosis can be confirmed with relation to cardiac enzymes
Impacts speed and treatment
How would you interpret pleuritic chest pain ?
How would you determine the risk of MI as a differential from the history
Not particularly indicative of CV cause
- pericarditis?
- think respiratory or chest inflammation
No history of exercise or exertion before event => MI is less likely
- chronic stress and depression over long term => may mimic MI with ECG changes (takotsubo)
- pain replicated by positional change/palpation => MI unlikely (could be from a fall?)
How would you interpret radiation
LOCATION OF PAIN DOESNT DICTATE THE LOCATION OF THE PATHOLOGY
Substernal/left of chest => arms, jaw, throat
Esophageal pathology can also present retrosternally
What information would you like to know from a patient with
- syncope
- palpitations
- tachycardia
Syncope
-try to get a collateral, patient may be confused
Palpitations, tachycardia
- duration, severity
- provocations (drugs, ETOH)
What are the key CV diagnostic investigations
CXR
- acute, chronic HF?
- mediastinal widening?
CT => may be indicated depending on presentation and differentials
-aortic dissection
ECHO => problems with wall, valves
Bloods => TNT, DDimer, FBC, U&E, LFT, clotting, lipid profile, plasma glucose
ABG
