Differential diagnosis of chest pain Flashcards
Where do sympathetic nerves exit the spinal cord?
They travel inferiorly in the spinal cord
They exit between the T1 and L2 vertebrae (Thoracolumbar outflow)
What 5 things can occur after the sympathetic nerves exit the spinal cord?
- It can go into the ganglion of the same level from which it exited
- It can travel superiorly in the sympathetic chain to another, higher ganglion
- It can travel inferiorly in the sympathetic chain to another, lower ganglion
- It can pass straight through the sympathetic chain without synapsing, becoming an abdominopelvic splanchnic nerve, before synapsing onto one of the paravertabral ganglia of the abdomen
- Pass straight into the adrenal medulla, without synapsing, becoming an abdominopelvic splanchnic nerve, directly stimulating adrenaline release
What are the 2 types of splanchnic nerves?
Abdominopelvic splanchnic nerves
Cardiopulmonary splanchnic nerves
How do impulses reach the heart?
Via the cardiopulmonary splanchnic nerves
What is contained in the cardiac plexus?
Sympathetic fibres
Parasympathetic fibres
Visceral afferent fibres
How do parasympathetic nerves leave the CNS?
Either via cranial nerves: III (Occulomotor), VII (Facial), IX (Glossopharyngeal) and X (Vagus)
They also leave the spinal cord with the sacral spinal nerves (Sacrocranial outflow)
Which nerve carries parasympathetic nerves to the heart?
Vagus nerve (Cranial nerve X)
Where would somatic pain in the chest arise from?
Muscles
Joints
Bones
Intervertebral discs
Fibrous pericardium
Nerves
Where would visceral pain in the chest arise from?
Heart and great vessels
Trachea
Oesophagus
Abdominal viscerae
What type of pain is associated with somatic pain?
Sharp, stabbing and well localised pain
What type of pain is associated with visceral pain?
Dull, aching, nauseating and poorly localised pain
Where would radiating pain from the chest be felt?
Upper limbs
Back
Neck
Jaw
Where would referred pain from the chest be felt?
Upper limbs
Back
Neck
Jaw
What is meant by radiating pain?
Pain that is felt in the centre of the chest and is felt spreading from there to other areas
What is meant by referred pain?
Pain that is only felt at a site, remote from the actual area of pathology
What are the 4 main lobes of each hemisphere of the brain?
Frontal lobe
Parietal lobe
Temporal lobe
Occipital lobe
Where does pain reach consciousness?
In the cerebral cortex
Where is the central sulcus found?
Between the frontal and parietal lobe
What is found anterior to the central sulcus?
The pre-central gyrus of the frontal lobe (Somatomotor section of the cerebral cortex)
What is found posterior to the central sulcus?
The post-central gyrus of the parietal lobe
What is brought about by action potentials arising in the pre-central gyrus of the frontal lobe?
Contractions of the body wall skeletal muscle
What is brought about by action potentials arising in the post-central gyrus of the parietal lobe?
Body wall sensations are brought into consciousness
What is shown by the sensory homunculus?
The areas of the cerebral neocortex (Outermost layer of the cerebral cortex) of a coronal section of the post-central gyrus
In which hemisphere of the brain would a prod to the right side of the chest be brought into consciousness?
The left, due to crossing over in the spinal cord?
What are some examples of sharp, central chest pain sources?
Herpes zoster (Shingles)
Muscle, joint and bone problems
Parietal pleura and fibrous pericardium problems
How does Herpes Zoster cause pain?
Herpes zoster (Shingles) is a reactivation of a dormant virus in the posterior root ganglion
This can cause stabbing pain anywhere in that dermatome and will proceed painful blisters
Patients with shingles developing n the T4/T5 dermatome may present with central stabbing chest pain
What are some examples of muscle, joint and bone problems that can be felt as central, stabbing chest pain?
Pectorals major or intercostal muscle strain
Dislocated costochondral joints
Slipped thoracic intervertebral disc
What are some examples of problems of the parietal pleura and fibrous pericardium that can be felt as central, stabbing chest pain?
Pleurisy - Inflammation of the parietal pleura
Pericarditis - Inflammation of the fibrous pericardium
What are some sources of dull, central chest pain (9) ?
Tracheitis
Rupture aneurysm of the aortic arch
gastritis
Cholecystitis - Swelling of the gallbladder
Pancreatitis
Hepatitis
Angina
Myocardial infarction
Oesopagitis
What are the 2 main divisions of the mediastinum?
Superoir mediastinum
Inferior mediastinum
What marks the border between the 2 divisions of the mediastinum?
A horizontal line between the sternal angle and the T4 intervertebral disc
What are the 3 divisions of the inferior mediastinum?
Anterior mediastinum
Middle mediastinum
Posterior mediastinum
What is the lower border of the mediastinum?
The diaphragm
What is the function of the azygous vein?
Drains venous blood from the internist spaces
What is the ligamentum arteriosum?
A smal ligament attaching the arch of the aorta and the pulmonary trunk
It is a remnant of the ductus arteriousus
Where does the left recurrent laryngeal branch of the left vagus nerve travel?
It hooks around the ligamentum arteriosum
What structures are present in the posterior mediastinum?
Oesophagus x1
Thoracic aorta x1
Thoracic duct x1
Sympathetic chains x2
Azygous vein x1
Vagus nerves x2
What types of nerve fibres are carried in the cardiopulmonary splanchnic nerves?
The cardiopulmonary splanchnic nerves carry the post-synaptic sympathetic fibres to the heart and visceral afferent fibres away from the heart
How does pain travel from the heart to the brain?
Visceral afferent App pass bilaterally to the thymus and hypothalamus before diffusing to different areas of the cortex
How does radiating pain arise?
Somatic sensory fibres can enter the spinal cord at the same dermatome as visceral afferent nerves, thus creating confusion
Where would radiating pain originating in a somatic structure be felt?
Anywhere along the same dermatome
Where would radiating pain originating in a visceral structure be felt?
It will be felt in the dermatomes supplied by the spinal cord at levels in which visceral afferent fibres also pass, so bilaterally to cervical and upper thoracic dermatomes
What causes referred pain?
Afferent, sensory fibres from the soma and afferent, sensory fibres from the viscera enter the spinal cord at the same levels, so the brain chooses to believe that the pain signals are coming from the soma and not the organ
What is meant by a myocardial infarction?
Irreversible death (Necrosis) of part of the myocardium, due to occlusion of its arterial blood supply
How are myocardial infarctions classified?
According to the surface of the heart that is affected
What are the 3 classes of myocardial infarction?
Anterior MI
Inferior MI
Anterolateral MI
What are the 4 most common sites of coronary atherosclerosis?
1- Left Anterior Descending artery
2- Right Coronary artery
3- Circumflex artery
4- Left Main Stem Coronary artery
What is meant by triple vessel disease?
Occlusion of the LAD, RCA and circumflex artery
What is performed to treat triple vessel disease?
A triple bypass surgery to return blood flow to the myocardium
What is involved in Coronary Artery Bypass Grafting (CABG)?
Grafts are anastomosed to the ascending aorta and the occlusion are bypassed as the grafts are connected to the blood vessels past the occlusion
What are the 3 main places from which grafts can be taken?
Great saphenous vein - Lower limb
Radial artery
Internal thoracic (Internal mammary) artery
What is meant by grafting ‘by pedicle’?
One end of the original artery remains in tact while the other is attached to the myocardium
Which vessel is grafted by pedicle?
Internal thoracic (Internal mammary) artery
Which artery supplies the Sino-Atrial Node?
The Sino-Atrial Nodal artery - Branch of the right coronary artery (Near RCA origin)
Which artery supplies the Atria-Ventricular Node?
The Atria-Ventricular Nodal artery - Branch of the right coronary artery (Near PIV origin)
