Jaynstein - Chest Pain Flashcards
what is levine sign
clutching of chest with severe pain
5 broad ddx for CP
CV
trauma/MS
pulmonary
infectious
other
3 CV do not miss causes of CP
ACS
AAA
AS
4 trauma/MSK causes of CP
chest wall fx/contusion
PTX
boerhaaves syndrome
costochondritis
aortic stenosis triad
SAD:
syncope
angina
dyspnea
pulmonary cause of CP
PE
3 infectious causes of CP
pleurisy
PNA
myocarditis
other causes of CP
GERD
esophageal
PUD
GB
psych -> severe anxiety
toxicity -> cocaine
t/f: vast majority of pt’s who are having an MI present to ED
t!
mc cause of CP in primary care setting
chest wall syndrome (CWS)
what is CWS
MSK related chest wall pain
not an emergent dx
ex of CWS
costochondritis
don’t diagnose CP as __
nonspecific or atypical CP
call it CWS or non coronary related CP
3 main goals of CP eval
determine stable vs unstable
low risk vs who needs referral/testing
who needs prompt transfer
indications for emergent ER transport
any concern for ABC’s outside of acceptable range (not necessarily “normal” range)
2 indications that pt likely does not need emergent care
no respiratory distress
vitals within acceptable range
just move on to complete H&P
management of unstable pt w. CP
- O2
- call 911
first step in op management of CP (stable pt)
ECG
if no ECG in office, get them somewhere else (probs ED)
2 commonly missed history questions w. CP
-have you had pain like this before
-have you ever had a heart exam/work up (if normal stress test in last 90 days, unlikely to be ACS)
how many baby ASA equals a full dose of ASA
4
sign pointing to GI CP
postprandial
red flags for cardiac CP
worse with:
exertion
cold
emotional stress
sex
CP worse with body position/movement/deep breathing is indicative of
MSK origin
relief w. sublingual nitro suggests CP related to (2)
cardiac
esophageal
NOT DIAGNOSTIC THO!
relief of CP w. GI cocktail is indicative of CP related to (2)
GI
cardiac
NOT DIAGNOSTIC
cessation of pain w. rest is indicative of CP related to
cardiac
relief of pain w. sitting up and leaning forward suggests
pericarditis
vomiting may indicate CP related to (2)
MI
GI
diaphoresis is most likely indicative of CP related to
MI
syncope w. CP is concerning for (4)
dissection
PE
critical AS
AAA
2 symptoms VERY concerning for MI
syncope
diaphoresis
near-syncope w. CP is most likely
myocardia ischemia
__ can be only presenting complaint of MI in elderly pt
fatigue
radiation of CP to __ is strong predictor of acute MI
arms
radiation of CP to scapula is concerning for __
aortic dissection
nonspecific CP radiation is concerning for __
ischemic etiology
what aspect of pain is NOT a useful predictor for presence of CAD
severity
abrupt onset of pain w. greatest intensity in the beginning is concerning for (3)
PTX
dissection
acute PE
gradual CP that increases over time
ischemia
crescendo CP pattern
esophageal dz
CP that lasts for seconds or is constant over weeks is not __
ischemic
CP associated w. circadian rhythm
ischemia
correlates w. sympathetic tone
ischemic pain mc occurs during what time of day
morning
3 hx red flags w. CP
prior CV hx
GI hx (ex biliary colic)
fam hx
rf for cardiac causes of CP
age
tobacco use
fam hx
DM
HTN
HLD
cocaine
DVT/PE
marfans
pregnancy
etoh
NSAIDs
red flag exam findings for ACS
S3 or S4
sbp < 80
crackles on auscultation
t/f: hypotensive MI is more concerning than hypertensive MI
t!
likelihood ratio > __ indicates test result is associated with dz
1
likelihood ratio < __ indicates result is associated w. absence of dz
1
LR of 2 increases probability of test result/dz association by __
15%
LR of 5 increases probability of test result/dz association by __
30%
LR of 10 increases likelihood of test result/disease association by
45%
in medicine, LR > __ is considered very highly significant
10
clinical feature most significantly associated w. MI
pain radiation to BOTH arms
not just left or right
9 clinical features statistically significantly associated w. MI
pain radiation to both arms or either arm
non exertional pain
S4
hypotn
prior MI
crackles
diaphoresis/n/v
pain described as pressure
pain worse than previous MI
7 clinical features significantly associated w. MI
pain radiation to both arms or either arm
S4
hypotn
prior MI
crackles
diaphoresis/n/v
pressure/crushing pain
pain worse than previous MI
5 clinical features that statistically decrease likelihood of MI
pleuritic/sharp/stabbing/positional pain
reproducible pain
exertional pain
inframammary pain
pain reproducible w. palpation
EKG AMI criteria
ST elevations > 2 mm in continuous leads
ischemia EKG criteria (3)
> 2 mm Q waves in inferior leads
ST depression in continuous leads
T wave inversion in continuous leads
if pt has concerning EKG, you will send them to ER, if EKG is wnl, what do you do
troponin to evaluate for NSTEMI
evaluate for non cardiac causes (ex CXR)
ED troponin SOC
> 3 hr from onset of sx: initial trop only
< 3 hr from onset of sx: need 2nd trop 1 hr later
safest management of ACS in op setting no matter the time from onset of sx
transfer to ER w.o trop testing
when is it reasonable to order op trop
single trop if no rf and nl EKG and symptoms have resolved at least 12 hr prior
should you ever order a trop if you are sending pt to ED
no!
management of pt who has work up for CP that is not concerning for MI (4)
arrange for cardiac stress testing w.in 3-7 days
start PPI minimum of 2 wk trial)
start daily baby ASA
strict “to ER” precautions
mc PE findings of pt w. ACS
normal
2 helpful PE findings helpful to r.o MI
reproducible CP
pain w. palpation
3 labs helpful in evaluation of CP
CBC (if you think there is an infectious cause)
CMP
trop
t/f: you can use HEART Score in primary care setting
F!
you need troponin first
what is included in the HEART score
history
ECG
age
RF
Troponin
post prandial CP can be an atypical presentation of
ischemia
4 emergent causes of CP
ACS
aortic dissection
PE
PTX
7 urgent causes of CP
pericarditis
pulmonary HTN
myocarditis
esophageal rupture
biliary tract dz
pancreatitis
PNA
other causes of CP (6)
GERD
PUD/gastritis
esophageal spasm
costochondritis/CWS
herpes zoster
anxiety
3 classic PE findings of ACS
normal
tachy
new murmur
EKG findings in aortic dissection
normal
4 classic findings of aortic dissection
distressed
wide mediastinum on CXR
pulse defects
neuro findings
3 EKG findings of PE
sinus tachy
RBBB
S1Q3T3
3 classic findings of PTX
tracheal shift
lucency on CXR
shock if tension
3 classic findings of pulmonary HTN
elevated JVP
loud S2, S4
increased markings on CXR
5 classic findings of myocarditis
+/- elevated trop
leukocytosis
new murmur
tachy
HF
2 classic findings of esophageal rupture
mediastinal air on CXR
crepitus
4 classic findings of biliary tract dz
murphy sign
+/- jaundice
fever
abnl LFTs
2 classic findings of pancreatitis
elevated amylase/lipase
elevated LFTs if gallstone
4 classic findings of PNA
fever
leukocytosis
rhonchi/rales
infiltrates on CXR
3 classic findings of GERD
relieved by GI cocktail
normal work up
esophagitis on EGD
2 classic findings of PUD/gastritis
epigrastric tenderness
guaiac (+) stools
classic finding of esophageal spasm
better w. nitro
classic finding of costochondritis/CWS
localized tenderness
reproduced w. palpation
classic finding of herpes zoster
CP before rash
what do you think when you see unilateral, localized CP w. (or followed by) rash
herpes zoster
pleuritic CP w. violent vomiting
esophageal rupture
3 rf for aortic dissection
HTN
smoking
marfans
aortic dissection symptoms can mimic ___ sx
stroke sx
