January 13, 2016 - SG2 - Chest Discomfort II

Question 1

DDx for Chest Discomfort

Answer 1

Falls into one of three broad categories…

1. Cardiac
2. Pulmonary
3. Other

Question 2

DDx for Pulmonary Chest Discomfort

Answer 2

The pleura may be involved - pneumothorax, pleurisy, or a tension pneumothorax*

The parenchyma may be involved - pneumonia, or a neospasm

The vasculature may be involved - pulmonary embolism*

* = may kill you

Question 3

DDx for Cardiac Chest Discomfort

Answer 3

Could be pericardial - pericarditis, pericardial effusion, pericardial constriction, or a tamponade*

Could be myocardial - systolic dysfunction, diastolic dysfunction, cardiomyopathies, or myocarditis

Could be valvular - regurgitation, stenosis, or sub-valvular disease

Could be vascular - stable angina, acute coronary syndrome*, or aortic dissection*

Question 4

DDx for “Other” Chest Pain

Answer 4

Could be gastrointestinal - GERD, cholecystitis, peptic ulcer disease, pancreatitis, esophageal spasm, or esophageal perforation*

Could be MSK - trauma

Could be neurologic - anxiety/panic, HZV / post-herpatic neuralgia, spinal radiculopathy

* = could kill you

Question 5

Acute Coronary Syndrome - Profile

Answer 5

History - crushing, retrosternal, brief, radiation to the jaw/arms. Often has coronary risk factors

Physical Exam - May show S4, paradoxical splitting of S2, MR murmur

Labs - Troponin T (best marker of injury)

ECG - ST elevation or depression, T-wave inversion. Q-waves late.

Question 6

Pericarditis - Profile

Answer 6

History - Pleuritic pain, worse when supine, better when sitting

Physical Exam - maybe a triphasic rub

Labs - none

ECG - diffuse ST elevation, PR depression

Question 7

Aortic Dissection - Profile

Answer 7

History - sudden onset “ripping” pain to the back. History of hypertension or Marfan’s syndrome

Physical exam - differential blood pressure in both arms

Labs - no specific

ECG - If dissect RCA, inferior (II, III, AVF) ST elevation

Question 8

Pulmonary Embolism - Profile

Answer 8

History - abrupt pleuritic chest pain, dyspnea. History of DVT and risk factors (Virchow’s Triad)

Physical Exam - Depends on size. Possible DVT signs and symptoms. Elevated JVP.

Labs- D-Dimer present (good negative predictive value)

ECG - sinus tachycardia

Question 9

Pneumonia - Profile

Answer 9

History - fever, cough, sputum

Physical Exam - tachypnea, fever, tactile fremitus, bronchial breathing, crackles, egophony, +/- effusion signs

Labs - CXR: air bronchograms, silhouette sign, effusions

ECG - sinus tachycardia

Question 10

Pneumothorax - Profile

Answer 10

History - sudden onset of sharp chest pain, dyspnea. Risk factor: asthma, Marfan’s syndrome, previous pneumothorax

Physical Exam - decreased chest excursion on the affected side, diminished breath sounds, hyperresonant to percussion. Tracheal deviation away if tension.

Labs - CXR: “pleural line”

ECG - sinus tachycardia

Question 11

Well’s Score

Answer 11

Clinical probability for a pulmonary embolism.

Clinical signs and symptoms of DVT - 3

Tachycardia - 1.5

Immobilization for >3 days or surgery in last 4 weeks - 1.5

Previous PE or DVT - 1.5

Hemoptysis - 1

Cancer - 1

PE more likely than anything else - 3

<2 = low probability

2-6 = moderate probability

>6 = high probability

Question 12

Slightly Elevated Troponin T

Answer 12

Not necessarily indicitive of a heart attack, as any damage can cause the release of a little bit of troponin. In the case of pulmonary embolism, troponins may be slightly elevated because of RV strain.

Question 13

Managing Pulmonary Embolism

Answer 13

Need to put the patient on anti-coagulatory drugs; IV unfractionated heparin, LMWH or rivaroxaban.

Admit to hospital if complicated.