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
What are the signs of mitral valve prolapse?
Mid-systolic click and late systolic murmur at the apex
What first line investigations would you consider in mitral valve prolapse?
ECG: usually normal, may show atrial fibrillation or other arrhythmias
What other investigations would you consider in mitral valve prolapse?
CXR: usually normal, may show enlarged pulmonary artery or left atrium
Echocardiogram: mitral regurgitation and valve prolapse
What are the symptoms of pneumothorax?
Acute, pleuritic chest pain, shortness of breath; primary spontaneous between ages 20 and 40 years; secondary spontaneous in patients with COPD; traumatic due to acute trauma or iatrogenic; shock may occur if rapidly increasing (tension pneumothorax)
What are the signs of pneumothorax?
absent breath sounds, increased resonance to percussion; jugular venous distention, tracheal deviation, and hypotension if tension pneumothorax (due to compromise of the great vessels)
What investigations would you consider in pneumothorax?
CXR: air in the pleural space, visible pleural line from collapsed lung, or mediastinal shift
What are the symptoms of pulmonary hypertension?
cardiac-sounding chest pain on exertion, dyspnoea; symptoms of right-sided heart failure such as lower extremity oedema, abdominal bloating, or ascites; syncope if severe
What are the signs of pulmonary hypertension?
accentuated pulmonic component (P2) to the second heart sound; palpable P2; right ventricular heave; lower extremity oedema; jugular venous distention
What are the first line investigations that you would do for pulmonary hypertension?
ECG: right axis deviation; right ventricular hypertrophy or right atrial enlargement
What are other investigations that you would consider for pulmonary hypertension?
CXR: large, prominent pulmonary arteries
echocardiogram: tricuspid regurgitation; estimated right ventricular systolic pressure >35 mmHg; right ventricular and right atrial dilation; pericardial effusion
What are the symptoms of peptic ulcer disease?
gastric ulcers: epigastric pain or burning with onset 5 to 15 minutes after eating and may last for several hours; duodenal ulcers: epigastric pain is relieved by eating and may return 1 to 4 hours postprandially; pain from any ulcer is relieved by antacid; risk factors: cigarette smoking, non-steroidal anti-inflammatory drugs, and chronic alcohol consumption
What are the signs of peptic ulcer disease?
epigastric tenderness; if significant bleeding is present there may be tachycardia, hypotension, and conjunctival pallor
What first line investigations would you consider in peptic ulcer disease?
oesophagogastroduodenoscopy: gastric or duodenal erosions or ulceration
What are other investigations you would consider in peptic ulcer disease?
Helicobacter pylori breath test: may be positive
What are the symptoms of oesophageal spasm?
crushing substernal chest pain, associated dysphagia, pain does not always correlate with swallowing, dysphagia precipitated by very hot or cold foods, glyceryl trinitrate can relieve the pain
What are the signs of oesophageal spasm?
no specific findings
What first line investigations would you consider in oesophageal spasm?
barium swallow: corkscrew or rosary bead appearance on barium swallow
What other investigations would you consider in oesophgeal spasm?
oesophageal manometry: simultaneous contractions on >30% of wet swallows
What are the symptoms of acute cholecystitis?
right upper quadrant pain, radiation to the interscapular area or right shoulder, associated with nausea and vomiting, fevers, anorexia often accompanies pain, signs of peritoneal inflammation such as abdominal pain with jarring
What are the signs of acute cholecystitis?
right upper quadrant tenderness (Murphy’s sign), abdominal rigidity and guarding if perforation of the gallbladder, rarely have jaundice early in the course of cholecystitis
What first line investigations would you consider in acute cholecystitis?
liver function tests: may be elevated alkaline phosphatase and gamma-GT
FBC: leukocytosis with a left shift
abdominal ultrasound: pericholecystic fluid, distended gallbladder, thickened gallbladder wall, and gallstones
What other investigations would you consider in acute cholecystitis?
hydroxy-iminodiacetic acid (HIDA) scan: decreased radionuclide uptake in the gallbladder due to cystic duct obstruction
What are the symptoms of acute pancreatitis?
epigastric or periumbilical abdominal pain that radiates to the back; may be severe; associated nausea and vomiting; history of alcohol consumption or gallstones
What are the signs of acute pancreatitis?
tachycardic, hypotensive, febrile, acute distress; ecchymosis in the periumbilical region (Cullen’s sign) and the flank (Grey-Turner sign)
What first line investigations would you consider in acute pancreatitis?
serum lipase: double the upper limit of normal values
What other investigations would you consider in acute pancreatitis?
FBC: leukocytosis
electrolytes and renal function: elevated creatinine, high anion gap
ABG: acidosis, low pH
abdominal ultrasound: determines possible cause, such as gallstones
abdominal CT scan: stage the severity of the pancreatitis; pancreatic necrosis; pseudocyst
What are the symptoms of herpes zoster?
unilateral, burning pain in typical dermatome distribution that may occur before appearance of rash and may persist for >1 month
What are the signs of herpes zoster?
vesicular rash on erythematous base, in unilateral distribution of a dermatome
What first line investigation would you do for Herpes Zoster?
usually no test required: diagnosis is clinical
What other investigation would you consider for herpes zoster
swab for viral culture and PCR: varicella-zoster positive on culture, immunofluorescence, or PCR
What are the symptoms that you would consider for gastritis?
dyspepsia/epigastric discomfort; nausea, vomiting, loss of appetite; history of NSAID use or alcohol misuse; history of Helicobacter pylori infection; history of previous gastric or abdominal surgery
What are the signs that you would consider for gastritis?
epigastric gastric discomfort may be present; may have signs associated with vitamin B12 deficiency and pernicious anaemia (e.g., abnormal neurological examination, presence of cognitive impairment, angular cheilitis, atrophic glossitis
What are the first line investigations that you would consider for gastritis?
Helicobacter pylori urea breath test: positive in H pylori infection
What other investigations would you consider for gastritis?
oesophagogastroduodenoscopy: results can be variable; may show atrophy and/or erosions
gastric mucosal biopsy: variable; positive for H pylori ; features of acute or chronic gastritis
