Chest pain Quiz - Ch17 Flashcards
What is classically described cardiac chest pain
- retrosternal in the left anterior chest
- radiation of pain to left shoulder, jaw, arm, or hand
- associated sx of dyspnea, diaphoresis, nausea
what patients are at risk for having non-classic presentations of ACS
- premenopausal and early menopausal women
- racial minorities
- DM
- elderly
- psych disease or AMS
what two specific things can accelerate atherosclerosis and therefore increases risk of ACS
- HIV
- cocaine
oddly specific idk why
what increases the likelihood that pain is due to an acute myocardial infarction (AMI)
- radiation of pain to arms
- worse w exertion
- diaphoresis and N/V
How is the physical exam for ACS patients
often can be normal but you may see:
- tachycardia/bradycardia
- 3rd/4th heart sounds
- new murmur (rupture of cordae tendineae or Aortic root dissection)
- crackles in lungs (CHF)
- chest wall tenderness (15% of AMI pts)
how soon after arrival should chest pain patients receive an EKG
10 minutes
what EKG finding supports the dx of AMI
new ST segment elevations >/= 1mm in 2 contiguous leads.
what EKG findings support the diagnosis of ischemia and require further evaluation
- new ST elevations (not 1mm not contiguous)
- Q waves
- LBBB
- T wave inversion
(not enough to dx AMI but should be further evaluated)
why is a CXR useful in the dx of AMI
- AMI cxr will be normal.
- useful to r/o other dx such as thoracic aortic aneurysm, pna, or pneumothorax.
if you are suspecting pulmonary embolism or aortic dissection what imaging should be ordered
CT chest
which cardiac biomarker is the choice of detection for myocardial injury, why?
troponin (high sensitivity and nearly complete specificity)
How do you differentiate troponin that is elevated from an AMI vs troponin that is elevated from something such as CHF, PE, aortic dissection, ect.
based on the pattern of elevation.
in AMI, troponin elevates 2-6 hours after injury and may continue to elevate for up to 48 hours after injury.
they can stay elevated for up to 10 days.
what non cardiac disease can cause an elevated baseline troponin and should be taken into consideration when evaluating serial troponins
kidney failure.
what is the presentation for pulmonary embolism
- sudden onset
- pleuritic chest pain (worse w breahting)
- dyspnea, tachypnea, tachycardia, hypoxemia
what imaging is used to identify pulmonary embolism
CT pulmonary angiography
what is the presentation for arotic dissection
- sudden onset
- severe tearing pain radiating to interscapular area of the back
- unilateral pulse deficits (unequal pulses in arms)
- could see focal neurologic deficits
what are risk factors for aortic dissection
- male
- > 50
- uncontrolled HTN
- connective tissue disorder (marfans, ehlers-danlos)
- cocaine use
- valve replacement
- pregnancy
what is the workup for a suspected aortic dissection
- CT aortogram or transesophageal echo
- CXR (widened mediastinum)
- D-dimer (sometimes elevated)
- EKG (nonspecific ST seg or T wave changes)
what is the presentation of esophageal rupture
- sudden onset
- sharp, substernal chest pain following an episode of forceful vomiting
- ill appearing, tachycardic, febrile, with dyspnea and diaphoresis.
- PE shows crepitus is the neck/chest from subcutaneous emphysema (audible crepitus is NOT usually found)
what may be seen on a CXR of esophageal rupture
could be normal or may demonstrate pleural effusion, pneumothorax, pneumomediastinum, pneumoperitoneum, or subcutaneous air.
what is the diagnostic study for esophageal rupture
CT chest with oral water soluble contrast.
what is the presentation of spontaneous pneumothorax
- sudden onset
- sharp pleuritic chest pain with dyspnea
- may see decreased breath sounds on affected side.
what are risk factors for spontaneous pneumothorax
- tall slender male patients
- smoking
- COPD
- asthma
what diagnostic studies are used to dx spontaneous pneumothorax
chest Xray showing collapsed lung
what is the presentation of acute pericarditis
- sharp, severe, constant retrosternal pain that radiates to back, neck or jaw
- worse with supine, better with sitting forward
- PE shows pericardial friction rub
what is the diagnostics for acute pericarditis
diffuse ST segment elevations with PR segment depressions or T wave inversions.
presentation of musculoskeletal causes of chest pain
- sharp pain worsened w movement of the chest
- completely reproducible pain with palpation and clear msk etiology
GI causes
