Chest Pain & Pulmonary - Module 5 Flashcards
What are the most common causes of non-cardiac chest pain?
Muscoloskeletal, gastrointestinal, psychiatric, and pulmonary disease
How does life span relate to chest pain?
Younger patients have more benign underlying conditions. Older patieints (especially with comorbidities) are more likely to have serious causes. ALL patients should have cardiac & life-threatening non-cardiac conditions ruled out first.
What are nonmodifiable risk factors for coronary artery disease (CAD)?
Gender, age( male >45; female >55), family history of premature CHD
What are modifiable risk factors for CAD?
Smoking, dyslipidemia (low HDL: 130) , diabetes mellitus, increased waist to hip ratio, physical inactivity, poor diet, psychosocial stress, poor dental health, and hypertension
What determines the risk for cardiovascular events?
The composition, morphology and stability of the coronary artery plaque. NOT the degree of plaque stenosis.
When should the patient with chest pain be sent to the ER?
Hemodynamic instability; positive ancillary studies (ECG, pulse ox, CBC, ABG, serum cardiac biomarkers, CXR,Echo, stress test, angiography) or high clinical suspicion.
Clinical Presentation - Cardiac Chest Pain Quality:
Vise-like pressure; constricting.
Clinical Presentation - Location:
What does pain that localizes to a small area of the chest suggest?
Pleural or chest wall involvement
Clinical Presentation - Intensity:
What causes an abrupt onset of pain with the greatest intensity at the beginning?
Aortic dissection, pneumothorax, or pulmonary embolism.
Clinical Presentation - Intensity:
What causes a more gradual onset of pain?
Ischemic chest pain
Clinical Presentation - Intensity:
When is the onset of pain more vague?
Psychogenic
Clinical Presentation - Duration
If the chest pain lasts only seconds or has been constant for weeks, it is NOT ___________.
cardiac
Clinical Presentation - Aggravation
Symptoms related to eating (dysphagia, odynophagia, & heartburn) suggest:
Esophageal chest pain
Clinical Presentation - Aggravation
Pain that worsens with exercise is reflective of:
cardiac ischemia
Clinical Presentation - Aggravation
Pain aggravated by position changes, deep breathing, or cough:
Musculoskeletal or pleural disorder
Clinical Presentation - Alleviation
Repeated relief from antacids or food:
Gastrointestinal source.
Clinical Presentation - Alleviation
Relief with nitroglycerin:
Esophageal and cardiac causes.
Clinical Presentation - Non-Cardiac Chest Pain Quality:
Sharp, stabbing, or knife-like pain
What words might a patient use to describe angina?
Variable; pressure, heaviness, aching, constriction, tightness, squeezing,numbness, or burning sensation.
Exam findings of MI:
1) Chest pain: pressure, heavinesss, squeezing, crushing, aching
2) Nausea & vomiting
3) Diaphoresis
4) Dyspnea
5) Possible atrial gallop (s4)
6) hypertension
NSTEMI (non-ST-segment elevation MI) is most often caused by _______________.
coronary artery narrowing caused by a non-occlusive thrombus (developed from a ruptured atherosclerotic plaque).
STEMI (ST-sement elevation MI) is most often caused _____________________.
when an atherosclerotic plaque ruptures, resulting in coronary artery occlusion.
Are ST-segment elevations or history and presenting symptoms more diagnostic of MI?
History and presenting sx
Difference between men & women presenting with MI?
Women will many times present with c/o indigestion. Women 20% mortality; men 8% mortality
Hx & Sx: recent orthopeadic surgery, sharp anterior chest pain, hemoptysis, RR-24, slightly decreased excursion and breath sounds at R base; Negative for chills, fever, orthopnea, calf pain
PE; Needs CXR; Send to ER
Key indicators for Dx of Asthma:
1) Wheezing
2) Hx of one: cough, recurrent wheeze, recurrent diff in breathing, recurrent chest tightness
3) Sx occur or worsen with : exercise, viral infection, inhalant allergens, irritants, changes in weather, strong emotional expression, menstrual cycles
4) Sx occur or worsen at night.
Dx of asthma is based on ___________, ____________, and ________________ ____________ especially _________________.
history, physical, diagnostic tests, spirometery
What is FEV1 and how does it change in mild asthma?
Forced expiratory volume at 1 second. It is reduced in mild asthma.
Intermittent asthma: Step 1 Tx?
SABA (short acting beta agonist - ex. albuterol) PRN; Short course of oral systemic corticosteroids may be needed
Persistent Asthma: Step 2 Tx?
Low dose Inhaled Corticosteroids
Persistent Asthma: Step 3 Tx?
ICS + LABA (long acting beta agonists) OR medium dose ICS
Persistent Asthma: Step 4 Tx?
Medium dose ICS + LABA
Persistent Asthma Step 5 Tx?
High dose ICS + LABA
Persistent Asthma Step 6 Tx?
High dose ICS + LABA + oral corticosteroid
Asthma Classification for: & Therapy step
Sx & SABA:< /= 2 days/wk
Niightime: 80% predicted
0/1 year times req’d oral sys corticosteroids
INtermittent; step 1
Asthma Classification for: & Therapy step
Sx & SABA: > 2 days/wk but not daily
Niightime: 3-4/month
Minor activity limitation
FEV1 >80% predicted
>/= 2/ year times req’d oral sys corticosteroids
Mild; Step 2
Asthma Classification for: & Therapy step
Sx & SABA: daily
Niightime: > 1/wk
Some activity limitation
FEV1 >60% predicted, but /= 2/ year times req’d oral sys corticosteroids
Moderate; Step 3
Asthma Classification for: & Therapy step
Sx & SABA: Throughout the day
Niightime: often 7x/wk
extreme limitation
FEV1 /= 2/ year times req’d oral sys corticosteroids
Severe; STep 4 or 5
Dx for Assessment:
Cough with or without sputum, occasional dyspnea or wheezing, normal VS, no tachypnea, tachycardia, rales, or egophany
Bronchitis
Diagnostic tests needed for bronchitis?
Generally, none are needed. Occasionally CXR if possible pneumonia
When can the need for CXR be eliminated?
Absence of: HR >100 RR >24 oral temp > 38 chest exam findings of focal consolidation, egophany, or fremitus
Differential dx for bronchitis which are characterized by wheezing, tachypnea, respiratory distress, and hypoxemia
pneumonia, asthma, bronchiolitis
First line tx for bronchitis
Directed toward symptom reduction- rest, increased fluids, humidified air
WHen to refer for bronchitis?
Does not repsond to symptomatic tx for 2 weeks
Who is at most risk for gram positive bacterial pneumonia?
People with other chronic conditions - DM, COPD, asplenia, advanced age, CHF, etc.
Dx for symptoms:
abrupt onset high fever, shaking, chills, productive cough with purulent sputum, posibble pleuritic type chest pains, consolidation (egophaony, fremitus, dullness onpercussion, rales, rhonchi). CXR - single or multiple lobar consolidation
Gram Positive pneumonia
Who is at most risk for gram Neg pneumonia
Older adults and those with chronic lung conditions
Who is at risk for atypical pneumonia
Less than 40 yr/old (older children & young adults)
Symptoms of atypical pneumonia
prodrome of fever, headache,myalgias, dry cough. CXR patchy alveolar densities
First line tx for pneumonia
macrolide abx
