Jaynstein - Chest Pain Flashcards by Alice Richards

what is levine sign

clutching of chest with severe pain

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5 broad ddx for CP

CV
trauma/MS
pulmonary
infectious
other

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3 CV do not miss causes of CP

ACS
AAA
AS

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4 trauma/MSK causes of CP

chest wall fx/contusion
PTX
boerhaaves syndrome
costochondritis

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aortic stenosis triad

SAD:
syncope
angina
dyspnea

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pulmonary cause of CP

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3 infectious causes of CP

pleurisy
PNA
myocarditis

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other causes of CP

GERD
esophageal
PUD
GB
psych -> severe anxiety
toxicity -> cocaine

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t/f: vast majority of pt’s who are having an MI present to ED

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mc cause of CP in primary care setting

chest wall syndrome (CWS)

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what is CWS

MSK related chest wall pain

not an emergent dx

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ex of CWS

costochondritis

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don’t diagnose CP as __

nonspecific or atypical CP

call it CWS or non coronary related CP

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3 main goals of CP eval

determine stable vs unstable
low risk vs who needs referral/testing
who needs prompt transfer

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indications for emergent ER transport

any concern for ABC’s outside of acceptable range (not necessarily “normal” range)

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2 indications that pt likely does not need emergent care

no respiratory distress
vitals within acceptable range

just move on to complete H&P

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management of unstable pt w. CP

O2
call 911

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first step in op management of CP (stable pt)

ECG

if no ECG in office, get them somewhere else (probs ED)

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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)

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how many baby ASA equals a full dose of ASA

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sign pointing to GI CP

postprandial

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red flags for cardiac CP

worse with:
exertion
cold
emotional stress
sex

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CP worse with body position/movement/deep breathing is indicative of

MSK origin

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relief w. sublingual nitro suggests CP related to (2)

cardiac
esophageal

NOT DIAGNOSTIC THO!

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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

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

likelihood ratio > __ indicates test result is associated with dz

likelihood ratio < __ indicates result is associated w. absence of dz

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

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