Chest Pain Uncommon Flashcards
What are the symptoms of pulmonary embolism?
Chest pain that is sharp and pleuritic
SOB
Haemoptysis (if there is pulmonary infarction)
Massive PE results in syncope
What are the risk factors for Pulmonary embolism?
History of immobilisation Orthopaedic procedures Oral contraceptive use Previous PE Hypercoagulable state Recent travel over long distances Unilateral swollen leg that is red and painful (suggests DVT)
What are the signs for PE?
Tachycardia Loud P2 Right-sided S4 gallop Jugular Venous Distention Fever Right ventricular Lift Massive PE may cause hypotension
What are the first line investigations for PE?
Wells criteria
ECG: sinus tachycardia, may show S1, Q3, T3 pattern
D-dimer: non-specific if positive; PE excluded if result is negative in patients with low probability of having a PE
CXR: may show decreased perfusion in the segment of pulmonary vasculature (Westermark sign); may show pleural effusion
CT pulmonary Angiography: may identify thrombus in the pulmonary circulation
What are the other investigations to consider in PE?
Echocardiography: may show acute right ventricular dilation or hypokinesis
V/Q scan: may show V/Q mismatch
Pulmonary Angiography: may identify thrombus in the pulmonary circulation
What are the symptoms of pericarditis?
Viral prodrome
Sharp pleuritic chest discomfort provoked by lying supine and improved with sitting up Dry cough
Fever
Myalgias/ arthralgias; history of possible causes such as radiation exposure, collagen vascular disease, recent myocardial infarction, or uraemia
What are the signs of pericarditis?
tachycardia and friction rub;
jugular venous distention and pulsus paradoxus indicate effusion causing tamponade
What first line investigations would you do for pericarditis?
ECG: diffuse concave-up ST-elevation, associated PR depression; changes evolve over time
What are the other investigations that you would consider for pericarditis?
CXR: usually normal; enlarged cardiac silhouette (globular heart) if pericardial effusion present
echocardiography: normal or shows small effusion
What are the symptoms of cardiac tamponade?
History of underlying cause such as myocardial infarction, aortic dissection, or trauma; may present insidiously as a result of hypothyroidism or pericarditis
Dizziness
Dyspnoea
Fatigue
What are the signs of cardiac tamponade?
Hypotension,
Distended neck veins, Muffled heart sounds; Pulsus paradoxus (a drop of ≥10 mmHg in arterial blood pressure on inspiration)
What are the first line investigations for cardiac tamponade?
ECG: low-voltage QRS; electrical alternans; other changes depend on underlying cause (e.g., ST elevation in acute myocardial infarction or non-specific ST changes in pericarditis)
CXR: globular heart (if large effusion)
What are other investigations to consider for cardaic tamponade?
Echocardiography: pericardial effusion causing collapse of great vessels, atria, and ventricles
What are the symptoms in Aortic Dissection?
Acute substernal tearing sensation, with radiation to interscapular region of the back; pain may migrate with the propagation of the dissection
Stroke, acute myocardial infarction due to obstruction of aortic branches
Dyspnoea due to acute aortic regurgitation; Hypotension due to cardiac tamponade; History of hypertension, Marfan’s syndrome, Ehlers-Danlos syndrome, or syphilis
What are the signs in Aortic Dissection?
Unequal pulses or blood pressures in both arms; New diastolic murmur due to aortic regurgitation
Muffled heart sounds if the dissection is complicated by cardiac tamponade
New focal neurological findings due to involvement of the carotid or vertebral arteries
What are the first line investigations that you would do in aortic dissection?
CXR: widened mediastinum
What other investigations would you consider in aortic dissection?
Transoesophageal echocardiography: false lumen or flap in the ascending or descending aorta, new aortic regurgitation or pericardial tamponade
CT chest with contrast: false lumen or flap in the ascending or descending aorta
MRI angiography: false lumen or flap in the ascending or descending aorta
What are the symptoms in aortic stenosis?
Age over 60 years Typical angina Chest pain is usually progressive SOB Syncope (if severe); patients with significant aortic stenosis and heart failure are at high risk of cardiogenic shock or sudden death
What are the signs in aortic stenosis?
Ejection systolic murmur that radiates to the neck Obliteration of S2 indicates severe stenosis
Delayed upstroke on palpation of carotid pulse
What are the first line investigations that you would do in aortic stenosis?
ECG: left ventricular hypertrophy; enlarged P wave suggesting left atrial enlargement
What other investigations would you consider in aortic stenosis?
CXR: calcified aortic valve; pulmonary oedema
Echocardiogram: poor excursion of aortic valve leaflets; elevated velocities through the aortic valve; possible left ventricular systolic dysfunction
What are the symptoms of mitral valve prolapse?
Usually asymptomatic, but may cause Palpitations Chest pain Dyspnoea Headache, Fatigue