M103 T3 L19 Flashcards
Which groups of structures in the chest can produce pain?
Cardiac Pericardial Oesophageal Pleural Vascular Musculoskeletal Neural
What are examples of cardiac conditions that can cause chest pain?
muscle death / infarction, ischaemia, infection
What are examples of Pericardial conditions that can cause chest pain?
inflammation, infection
What are examples of Oesophageal conditions that can cause chest pain?
spasm, inflammation, rupture, varices
What are examples of Pleural conditions that can cause chest pain?
infection, infarction, embolism, rupture / collapse
What are examples of Vascular conditions that can cause chest pain?
rupture, inflammation [vasculitis], infection
What are examples of Musculoskeletal conditions that can cause chest pain?
strain, spasm, tear, rupture, fracture
What are examples of Neural conditions that can cause chest pain?
‘precordial catch, referred pain, neuropathy
What are the two different types of structures that can cause chest pain?
superficial structures
deep structures
What are examples of superficial structures that can cause chest pain?
skin
breast tissue
ribs
What are examples of deep structures that can cause chest pain?
oesophagus respiratory tract lungs / pleura heart aorta spine
What areas is chest pain often referred to?
face liver arms neck (FLAN) chest pain generally moves UP
What are life threatening causes of chest pain?
Myocardial infarction / ischaemia myocarditis / pericarditis Pneumothorax Massive pulmonary embolus & infarction Ruptured aortic aneurysm Ruptured oesophagus Aortic dissection
What is the spectrum for the severity of chest pain under ACS?
stable angina
unstable angina
NSTEMI
What type of pain is described by patients with typical ACS chest pain?
central chest pain
usually accompanied by a squeezing or crushing sensation radiating up to the neck in the left arm
What symptoms is ACS chest pain usually associated with?
Diaphoresis
grey colour or pallor
Why are women more likely to experience a silent MI?
women often experience different classic symptoms to those of men - which are usually the only ones explained in the text books
What symptoms are women much more likely to experience when having a heart attack?
shortness of breath, dizziness or nausea
abdominal pain, tachycardia
What are words used to describe chest pain when taking histories?
Stabbing, knife-like, sharp
Gnawing, burning, numbing
Strangling, tightness, crushing, squeezing, constricting
Tearing, piercing
What does SOCRATES stand for?
Site Onset Character Radiation Associated symptoms Timing Exacerbation Severity
When might chest pain radiate into the right arm of a patient having a myocardial infarction rather than into the left arm?
if it is a rare case of the patient having Dextracardia
What are two terms associated with Acute Coronary Syndrome?
myocardial infarction
angina
In what order does an examination into ACS occur?
Inspection, Auscultation, Palpatation - IAP
BP, HR, RR
SaO2
What are the three types of investigations done in ACS?
bloods
CXR
ECG
What is chest pain in ACS usually relieved by?
nitrates
If nitrates aren’t working, why wouldn’t you give the patient morphine?
opiates can drive oxidative stress which is harmful
instead, statins to help stabilise plaques
What are the markers for ACS in the blood?
troponins - troponin T
C reactive protein or urea - indicates a lower respiratory tract infection
D-dimer - pulmonary embolism
When are D-dimers helpful?
when the result is negative bc they have a low false negative rate
has quite a high false positive rate bc it’s not very specific to blood clots (e.g. poor renal function, infection, post surgery after many weeks)
What signs would you look for on a CXR of a MI patient?
consolidation changes in the cardiac shadow changes in the the aortic notch inflation of the lungs trauma
What features would you expect on a ECG from an MI patient?
ST elevation is classical, but NSTEMI is also completely normal
What is the purpose of performing serial ECGs on a patient?
looking for dynamic changes
can indicate that there’s some cardiac stress
this is suggestive of ischaemia
What does the Oxford Handbook of Clinical Medicine state about all MI patients with a large PE?
that they will have the S1Q3T3 pattern, but that’s actually rare clinically
What is a potential indicator of pericarditis?
periodic or sharp sounding central chest pain
dynamic change on the serial ECGs surrounding a saddle-shaped ST segment
How many squares would the PR segment be on an ECG normally?
about 3 squares
What is the PR interval on an ECG indicative of?
delay at the AV node
What might be the cause for changes to the PR interval over serial ECGs?
if damage is sustained to the AV node. if it is defective in way it works
and if the patient has a condition like heart block (of first, second or third degree)
What are the effects of different degrees of heart block on the PR interval?
first - a delay
second & third - more complicated changes
What conditions might be associated with dyspensia?
gastritis
esophagiti
mucosal ulcers (might be the only symptom experienced)
What are some non-life threatening causes of chest pain in the heart?
heart burn
GORD
palpitations
What are some non-life threatening causes of chest pain in the musculoskeletal system?
Costochondritis
Tietze’s disease
non-penetrating trauma
How are palpitations usually described by patients?
bubbles in the chest / like they’ve been thumped in the chest
but they don’t tend to be painful
usually are quite self limiting, short lived and self resolving
What can the effects of non-penetrating trauma be if it is of sufficient force?
a pneumothorax
What combination of factors make it very likely that the patient is having a spontaneous pneumothorax?
young, slender, tall, male, active
What makes it more likely to be musculoskeletal in origin?
if the pain is reproducible on pressing or spraying of the chest
What makes it more likely to be musculoskeletal in origin?
if the pain is reproducible on pressing or spraying of the chest
What can pericarditis be caused by?
Can happen after an MI (Dressler’s)
Viral infection in context of ‘flu like illness
Coxsackie virus, mumps, herpes, HIV
How is osophageal pain usually described by patients?
burning, crushing, sharp, continuous, wave-like, or acute
When does osophageal pain usually get worse?
after eating
on bending forward / lying flat
raising head of bed
smoking
What can cause oesophageal rupture?
mediastinitis
spontaneous (following violent vomiting)
How is pleuritic pain usually described by patients?
Severe ‘sharp’, ‘stabbing’ or ‘knife-like’
usually one sided
worse on inspiration
What are the risk factors of pleuritic pain?
immobility, pregnancy, oestrogen therapy, obesity
What is the most common symptom of PE?
dysponea
What is shingles otherwise known as?
Herpes zoster
How does shingles usually present?
accompanied by a blistering rash with a dermatomal distribution – classically not passing the midline
What can nerve roots become compressed or irritated by?
vertebral body collapse (secondary to trauma or metastases)
metastatic growth and invasion
infection (including discitis)
