General Practice Flashcards
List causes of chest pain?
- Cardiac: ACS (unstable angina & MI), stable angina, dissecting thoracic aneurysm, pericarditis, cardiac tamponade, myocarditis, acute CCF, arrhythmia
- Respiratory: PE, pneumothorax, CAP, asthma, pleural effusion
- GI: acute pancreatitis, oesophageal rupture, peptic ulcer disease, GORD, oesophageal spasm, or oesophagitis
- MSK: rib fracture, costochondritis, spinal disorders (disc prolapse, cervical spondylosis, facet joint dysfunction), OA, RA, OP, fibromyalgia or polymyalgia rheumatica
- Other: lung cancer, herpes zoster, Bornholm’s disorder/ precordial catch (Texidor twinge), psychogenic/non-specific chest pain
List the 6 chest pain clinical features which would lead to hospital admission from a GP?
- RR >30bpm
- Tachy >130bpm
- SBP <90mmHg / DBS <60mmHg (unless normal for them)
- O2 sats <92% / central cyanosis (if no Hx of chronic hypoxia)
- Altered LOC
- High temp (esp >38.5°C)
List the 3 features of suspected ACS which would require hospital admission from a GP?
- Current chest pain
- Sx of complications (such as pulmonary oedema)
- Pain-free, but have had chest pain in the last 12 hours and have an abnormal ECG / ECG is not available
What are 2 ways to classify chest pain?
- Cause (cardiac, non-cardiac)
2. Type (localised, poorly localised, pleuritic, non-pleuritic
Describe what elements of a chest pain Hx indicate specific causes?
- Acute onset, with central/band-like pain which radiates to the person’s jaw, arms, or back –> cardiac
- Persistent, localised pain –> pulmonary / MSK
- Exertional chest pain –> angina
- Pleuritic chest pain –> pulmonary / MSK
- Breathlessness –> cardiac / pulmonary
- Associated with palpitations, dizziness, or difficulty swallowing is less likely to be angina
- Do not rule out stable angina on the basis of a normal resting 12-lead ECG
- An abnormal ECG makes the diagnosis of CAD more likely
- A recent normal coronary angiogram excludes CAD
- Stable angina or MI –> assess for CV risk factor (older age, male, smoking, HTN, DM, increased cholesterols, FHx CVD)
- Previous chest trauma- MSK, GI
- Anxiety/depression –> psychogenic or non-specific chest pain
Describe the examination you’d preform for chest pain?
- CV exam: Heart sounds (murmurs/pericardial rub), BP both arms (aortic dissection), pulse rate and rhythm (shock / arrhythmias), JVP, carotid pulse, ankles (oedema –> HF)
- Chest wall: palpate for tenderness, assess whether movement of the chest wall reproduces the pain (MSK), listen to lung fields (infection),
RR and pulse oximetry (low O2 sat) - General appearance: pallor and sweating (shock)
- Abdomen: tenderness (gallstones, pancreatitis, or peptic ulceration)
- Neck: localised tenderness and stiffness (cervical spondylosis or OA)
- Legs: swelling or tenderness (DVT)
- Skin: rashes (shingles) and bruising (rib fracture)
- Temp: especially >38.5ºC (infection, pericarditis, or pancreatitis)
List the investigations you’d perform if the patient did not require immediate admission/referral?
- ECG: vent hypertrophy/arrhythmia/PE/stable angina/ACS
- Blood glucose, lipid profiles, U&Es: CV risk profile
- FBC: anaemia which may exacerbate stable angina
- TFT: thyroid disease
- LFT & amylase: cholecystitis, pancreatitis
- CRP/ESR: infection/inflam (polymyalgia rheumatica, OA)
- CXR: HF/pleural effusion/lobar collapse/lung cancer
Describe the signs and symptoms of dissecting thoracic aneurysm?
- Symptoms: sudden tearing chest pain radiating to the back & inter-scapular region
- Signs: high BP, BP differentials (different in both arms), inequality in pulses (carotid, radial, femoral), a new diastolic murmur (aortic value regurgitation) & occasionally a pericardial friction rub, neuro deficits may be present (hemiplegia)
Describe the signs and symptoms of pericarditis/cardiac tamponade?
- Symptoms: sharp, constant sternal pain relieved by sitting forward, may radiate to the L shoulder and/or L arm into the abdomen, worse when lying on the L side and on inspiration, swallowing, and coughing. Fever, cough, and arthralgia. Tamponade may have breathlessness, dysphagia, cough, and hoarseness
- Signs: pericardial friction rub. Tamponade pulsus paradoxus (decrease in palpable pulse and arterial systolic blood pressure of 10 mmHg on inspiration), Beck’s Triad
What is Beck’s triad for a cardiac tamponade?
- Hypotension
- Muffled heart sounds
- Jugular venous distension
Describe the signs and symptoms of acute congestive HF?
- Symptoms: ankle swelling, tiredness, severe breathlessness, orthopnea, and coughing (rarely producing frothy, blood-stained sputum)
- Signs: elevated JVP, gallop rhythm, inspiratory crackles at lung bases, and wheeze
Describe the signs and symptoms of arrhythmias?
- Symptoms: chest pain associated with palpitations, breathlessness, and syncope/near syncope
- Signs: bradycardia / tachycardia
When would you suspect an ACS?
- Pain in the chest or other areas (for example the arms, back, or jaw) lasts >15mins
- Associated N/V, sweating or breathlessness, or a combo
- Associated with haemodynamic instability (SBP <90 mmHg)
- New-onset / result of an abrupt deterioration of stable angina, with pain occurring frequently with little or no exertion, and often lasting >15mins
How do you diagnose ACS?
- Resting 12-lead ECG: pathological Q waves, LBBB, ST elevation, T flattening/inversion
- Troponin I/T: increased indicates myocardial damage
List 4 causes, other than ACS, which can raised your Troponin?
- Arrhythmias
- Pericarditis
- PE
- Myocarditis
Describe the signs and symptoms of a PE?
- Symptoms: acute-onset breathlessness, pleuritic chest pain (worse on inspiration), cough, haemoptysis and/or syncope. Recurrent acute episodes may lead to chronic breathlessness
- Signs: tachypnoea >20BPM
Describe the signs & symptoms of pneumothorax?
- Symptoms: sudden-onset pleuritic pain and breathlessness in people with/ without pallor/tachycardia
- Signs: reduced chest wall movements, reduced breath sounds, reduced vocal fremitus, and increased resonance of the percussion note on the affected side. Tension pneumothorax can result in a rapid development of severe symptoms, tracheal deviation away from the pneumothorax, tachycardia, and hypotension
Describe the signs & symptoms of CAP?
- Symptoms: cough and at least 1 other symptom of sputum, wheeze, dyspnoea, or pleuritic chest pain
- Signs: any focal chest sign (dull percussion note, bronchial breathing, coarse crackles, or increased vocal fremitus or resonance) plus at least 1 systemic feature (fever or sweating, myalgia), with/ without temp >38°C
What may there be additionally signs of with a CAP?
Associated pleural effusion
Describe the signs & symptoms of asthma?
- Symptoms: wheeze, breathlessness, cough. Variable (worse at night, first thing in the morning, exercise or exposure to cold or allergens)
- Signs: there may be none when the person is feeling well. Acute episode, the RR increased, and wheeze present
Describe the signs & symptoms of lung/lobar collapse?
- Symptoms: localized chest pain, breathlessness, cough
- Signs: reduced chest wall movement on the affected side, dull percussion note with bronchial breathing, reduced or diminished breath sounds
Describe the signs & symptoms of lung cancer?
- Symptoms: chest / shoulder pain, haemoptysis, dyspnoea, weight loss, appetite loss, hoarseness, and cough
- Signs: finger clubbing, cervical or supraclavicular lymphadenopathy, thrombocytosis
Describe the signs & symptoms of pleural effusion?
- Symptoms: localised chest pain and progressive breathlessness
- Signs: reduced chest wall movements on affected side, stony dull percussion note, diminished or absent breath sounds, and (in heart / renal failure) signs of fluid overload
Describe the typical history of someone with acute pancreatitis?
May have a history of gallstones or excessive alcohol consumption
Describe the signs & symptoms of acute pancreatitis?
- Symptoms: sudden-onset pain typically severe, continuous, and boring in nature. Usually epigastric region, may be generalised. Radiate to the right upper quadrant, chest, flanks, and lower abdomen, relieved by sitting upright and leaning forward, and is worse in supine. Increases in severity to a peak during the first few hours, before reaching a plateau that may last for several days. N&V
- Signs: abdo tenderness, abdominal distension, Cullen’s sign (bluish discolouration around umbilicus), or Grey Turner’s sign (bluish discolouration around flank), and low BP. May be low-grade fever
Describe the typical history of someone with oesophageal rupture?
Recent history of a medical procedure, foreign body ingestion, or oesophageal cancer
Describe the signs & symptoms of oesophageal rupture?
- Symptoms: thoracic oesophageal perforation leads to chest pain, dyspnoea, and odynophagia
- Signs: fever and subcutaneous emphysema (around the neck & upper chest wall)
Describe the typical symptoms of peptic ulcer disease/GORD/ oesophageal spasm/ oesophagitis?
- Sub-sternal pain, which commonly occurs at night or after consumption of a large meal
- Epigastric pain often radiates to the throat and is worse when bending or lying flat
- Regurg of acid & food into the mouth
Describe the typical history of someone with acute cholecystitis?
History of gallstones (cholelithiasis). Cholecystitis without biliary colic usually has a gradual onset
Describe the signs & symptoms of acute cholecystitis?
- Symptoms: sudden-onset, constant, severe pain in the upper right quadrant, possibly anorexia, N&V, sweating. Low-grade fever
- Signs: tenderness in the upper right quadrant, with/without Murphy’s sign (inspiration is inhibited by pain on palpation). May also be fever (sepsis) and jaundice (stone in the bile duct / external compression of biliary ducts)
Describe the signs & symptoms of rib fracture?
- Symptoms: unilateral, sharp chest pain, worse with inspiration
- Signs: bruising and tenderness on palpation over the affected rib