Conditions

Question 1

Chest pain most common diagnoses?

Answer 1

The newer edition has musculoskeletal inflammation as first, most commonly a sprained muscle due to coughing. It also lists thoracic dissection and thoracic aneurysm.

Question 2

Common diagnosis for young female on COCP (3)?

Answer 2

PE, pneumothorax or cocaine-induced coronary spasm.

Question 3

Diagnoses that need immediate management?

Answer 3

ACS, aortic dissection, PE, pneumothorax, Boerhaaves perforation

Question 4

Features of Acute Coronary Syndrome?

Answer 4

History of sudden-onset, central, crushing chest pain radiating to arms, neck, jaw, lasting few mins to 30mins, high suspicion for those with previous MI or cardiovascular risk factors (smoking, hypertension, hypercholesterolaemia, DM, family history).

Question 5

Signs of hypercholesterolaemia?

Answer 5

cholesterol depositis on back of hand or bony prominences (xanthomata) or eyelids (xanthelasma) or ring around cornea (arcus).

Question 6

Signs of peripheral vascular disease (6)?

Answer 6

weak pulses, peripheral cyanosis, cool peripheries, atrophic skin, ulcers, bruits on auscultation of carotids.

Question 7

Signs of brady/tachy –arrhythmia?

Answer 7

could be the cause of the ischaemia, also arrhythmias most commonly occur in scarred myocardium, both from old infarcts and sometimes following an acute infarct.

Question 8

Features of aortic dissection?

Answer 8

History of sudden-onset tearing chest pain radiating to the back, pain is most intense from the onset. Absent pulse in one arm. Hypertension in 50%, hypotension in 25%. A difference in BP between the arms >20mmHg. New-onset aortic regurgitation, this is caused by the new lumen tracking down the aortic valve and making it incompetent. Pleural effusion, usually on the left. History of hypertension, smoking and atherosclerosis, may be had a recent aortic valve replacement.

Question 9

Features of pneumothorax?

Answer 9

History of sudden-onset pleuritic chest pain with breathlessness, but can present as painless breathlessness. A hyperinflated chest wall with impaired expansion. Hyper resonant percussion over affected area. Absent breath sounds over affected area

Question 10

Tension pneumothorax?

Answer 10

Tracheal deviation in tension pneumothorax, deviates mediastinum and can compress the heart leading to cardiopulmonary arrest. Trachea deviates away from pneumothorax. Its an emergency requiring a needle aspiration.

Question 11

Features of PE due to DVT?

Answer 11

History of sudden-onset shortness of breath (73%), pleuritic chest pain (66%), haemoptysis (13%) in someone with an inflamed limb and/or risk factors of blood clots (recent surgery, recent stasis, or hypercoagulable blood due to OCP or malignancy). Tachycardia. Signs of hypoxia; rare to find, some can desaturate on excertion. PE should be considered when there are no other explanation of chest pain.

Question 12

Features of Boerhaaves perforation?

Answer 12

Very rare but associated with high mortality. History of sudden-onset severe chest pain immediately following episode of vomiting. SOB and pleuritic chest pain may develop shortly after. Signs of pleural effusion after some hours (dullness to percussion, absent breath sounds, decreased vocal resonance).

Question 13

Full thickness vs partial thickness infarcts?

Answer 13

Full thickness infarcts; STEMI and posterior infarct. Partial thickness; NSTEMI.

Question 14

STEMI/NSTEMI management?

Answer 14

Management; ABC then MONABASH

Morphine; for analgesia, and an antiemetic like metoclopramide.

Oxygen; only in required to keep sats >94%.

Nitrates; (GTN or isosorbide mononitrate infusion) for vasodilation.

Antiplatelets; aspirin plus others like ADP receptor blockers.

Beta-blockers; to reduce myocardial oxygen supply.

ACE inhibitors; attenuation of post-infarct cardiac remodelling, reduction of angiotensin 2 induced vasoconstriction.

Statins; reduce cholesterol levels, maintain atherosclerotic plaque stability and prevent thrombus formation.

Herparin; prevent coronary thrombosis.

Question 15

STEMI/NSTEMI patients and thrombolysis/angioplasty

Answer 15

STEMI patients (including posterior infarcts) should also receive either primary angioplasty or thrombolysis within 12 hours of the onset of pain.

NSTEMI patients do not receive thrombolysis, as this does not appear to be effective in them. However, NSTEMI patients are candidates for early angioplasty if they are haemodynamically unstable, have severe left ventricular dysfuncion, or a high GRACE score.

Question 16

Secondary prevention of Ischaemic heart disease?

Answer 16

Lifestyle changes; stop smoking, low salt diet, exercise, weight loss.

Risk factor control with medications;

BP control; ACE inhibitors if the patient is <55 years and Caucasian, calcium-channel blockers or diuretic thiazides if the patient is >55 years or non-Caucasian.

Cholesterol reduction: statins or fibrates.

Diabetic control: tight sugar control is important for cardiovascular risk. Low dose aspirin for life and ADP receptor inhibitor (clopidogrel) for a 1 year.

Question 17

Common complications of MI?

Answer 17

Death, arrhythmia, rupture (either of the septum or the outer walls), tamponade, heart failure, valve disease, aneurysm, dressler’s syndrome (autoimmune pericarditis 2–10 weeks after MI; note that simple post-MI pericarditis is more common than Dressler’s syndrome, pre- senting within 2–4 days), embolism, re-infarction