Murtagh - Chest pain cont. management of other serious spontaneous causes of chest pain and musculoskeletal causes of chest wall pain

Question 1

aortic dissection

Answer 1

early diagnosis necessary - best achieved by transoesophageal echocardiography
50% of patients are hypertensive, so need pharmacological control of hypertension with IV nitroprusside and beta blockers
emergency surgery needed for many, especially type A (ascending aorta involved)

Question 2

pulmonary embolus investigations

Answer 2

chest x-ray and ECG
CT pulmonary angiography
radio nucleotide imaging - the V/Q study
digital subtraction angiography
d-dimer assay - useful but not specific
doppler sonography of lower limbs
arterial blood gases
wells score - if >3, probable. if >6, diagnostic.

Question 3

guidelines for when to drain a pneumothorax

Answer 3

most episodes resolve spontaneously without drainage

<25% collapse and no symptoms, observe
<25% collapse and symptoms, drain
>25% collapse, usually drain

Question 4

acute tension pneumothorax

Answer 4

for urgent cases insert a 12-16 gauge needle into the pleural space though the second intercostal space on the affected side
replace with a formal intercostal catheter connected to underwater seal drainage

Question 5

musculoskeletal causes/origins of chest wall pain

Answer 5

injury to the thoracic spine
- trauma
- osteoporosis
- metastatic disease
- multiple myeloma
intercostal muscle strains/tears
rib disorders
- fractures
- slipping rib
costochondritis
tietze syndrome
fibromyalgia

Question 6

features of musculoskeletal chest pain

Answer 6

typically aggravated by movements such as stretching, deep inspiration, sneezing and coughing
pain tends to be sharp and stabbing in quality but can have a constant aching quality

Question 7

costochondritis

Answer 7

common cause of anterior pain
localised to the costochondral junction and may also be a complaint of an inflammatory disorder, such as one of the spondyloarhtropathies

Question 8

management of costochondritis

Answer 8

generally conservative with analgesic creams and NSAIDs if there is an inflammatory component
other measures include local injection of anaesthetic with ir without corticosteroids or a specialised elasticated rib belt

Question 9

all sudden acute chest pain is

Answer 9

cardiac until proven otherwise

Question 10

mitral valve prolapse is often

Answer 10

an undiagnosed cause of chest pain
consider this if pain is recurrent and intermittent (proved by echocardiography)

Question 11

calcium antagonists may cause

Answer 11

peripheral oedema
be careful not to attribute this to heart failure

Question 12

the pain of oesophageal spasm can mimic

Answer 12

the pain of oesophageal spasm can be very severe and mimic myocardial infarction

Question 13

oesophageal spasm responds to

Answer 13

glyceryl trinitrate
do not confuse with angina

Question 14

intervertebral disc protrusions are a rare cause of

Answer 14

sudden severe thoracic pain

Question 15

INR ration needs to be kept between

Answer 15

2 and 3

Question 16

if a patient who is recovering from an AMI suddenly develops shortness of breath

Answer 16

consider ventricular septal rupture, mitral valve papillary rupture (with mitral regurgitation), pulmonary embolus and other serious complications

Question 17

all post MI patients would indefinitely be treated with

Answer 17

ACE inhibitors
all post MI and acute ischaemic syndrome patients with beta blockers