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Module 203 > Non-Cardiac Chest Pain > Flashcards

Non-Cardiac Chest Pain Flashcards

1
Q

<p>What is GERD </p>

A

<p>Condition in which the stomach contents (acid) moves backward from stomach to esophagus</p>

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2
Q

<p>What is the etiology of GERD?</p>

A

<p>1) Transient relaxation of Lower Esphageal Sphincter

2) Low basal LES tone
3) Acid Hypersecretion (Zollinger-Ellison syndrome) </p>

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3
Q

<p>Clinical features of GERD</p>

A

<p>1) Acid regurgitation and Pyrosis (Heart Burn)

| 2) May have sour taste, Waterbrash, Lump in throat sensation, Belching</p>

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4
Q

<p>How is GERD Investigated?</p>

A

<p>1) Clinical diagnosis most often based on symptoms and if there is relief from a trial of pharmacotherapy

2) Gastroscopy can identify complications such as esophageal ulcers, and Barretts esophagus
3) 24 hour ambulatory pH</p>

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5
Q

<p>Treatments for GERD?</p>

A

<p>1) Lifestyle: Elevate head of bed, avoid fatty/spicy foods,EtOH, Acid foods (coffee, tomatoes, citrus, quit smoking

2) PRN antiacids
3) H2 receptor antagonists and PPI </p>

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6
Q

<p>What are the 2 types of esophageal spasm?</p>

A

<p>1) Diffuse esophageal spasm

- Normal amplitude of contractions but uncoordinated
2) Hypertensive peristalsis
- coordinated contractions but of increased amplitude </p>

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7
Q

<p>How to diagnose Esophageal spasm?</p>

A

<p>1) Barium Swallow: can show contractions

| 2) Esophageal Manometry: measures pressure of esophageal contractions</p>

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8
Q

<p>4 Management strategies for esophageal spasms?</p>

A

<p>1) Phosphodiesterase inhibitor (Viagra) - relaxes smooth muscle

2) Botulinum toxin
3) Diet - puree foods, avoid triggers
4) Surgical (myotomy with findoplication) </p>

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9
Q

<p>Name 6 types of esophagitis</p>

A

<p>1) Reflux

2) Infectious
3) Pill
4) Eosinophilic
5) Radiation
6) Chemoradiation</p>

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10
Q

<p>Which investigations aid in the DX of esophagitis?</p>

A

<p>1)CBC in pts with neutropenia or immunosuppression
2) CD4 count, HIV testing if risk factors present
3) Collagen work-up based on underlying disease
4) Imaging
- Double contrast barium study
- Upper endoscopy
</p>

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11
Q

<p>TX of esophagitis</p>

A

<p>1) Hemodynamic stabilization and pain management

2) Depends of causal etiology
3) Surgury (fundoplication) may be needed
4) Medication
- PPI for GERD or ABX for infections </p>

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12
Q

<p>What is Fundoplication?</p>

A

<p>Surgery to prevent stomach contents from returning to the esophagus. Achieved by wrapping the upper portion of the stomace (fundus) around the lower portion of the esophagus </p>

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13
Q

<p>What is Boerhaave's Syndrome?</p>

A

<p>Spontaneous Rupture of the Esophagus </p>

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14
Q

<p>What causes Boerhaave's Syndrome?</p>

A

<p>- Sudden rise in intraluminal pressure

- Ex. Pressure produced during vomitting
- Commonly associated with overindulgence of food or alcohol </p>

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15
Q

<p>How does Boerhaave's Syndrome typically present?</p>

A

<p>- Repeated episodes of retching and vomiting

- Most common in middle aged men
- Recent dietary or EtOH intake
- No blood in emesis
- SOB
- Mackler Triad
- Pneumomediastinum </p>

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16
Q

<p>What is Mackler Triad and which condition is it associated with?</p>

A

<p>1) Vomiting

2) Lower Thoracic Pain
3) Subcutaneous Emphysema
* Associated with Boerhaave's Syndrome</p>

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17
Q

<p>Which investigation can help the DX of Boerhave's syndrome?</p>

A

<p>1) CBC - 50% of pts with this condition have a hematocrit value of about 50%, due to loss of fluid into pleural space
2) Thorocentesis: many pts present with plueral effusion. Undigested food particles and gastric juices often found in this fluid. pH under 6, elevated amylase and squamous cells from saliva may be seen</p>

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18
Q

<p>TX of Boerhaave's syndrome?</p>

A

<p>1) IV fluid resuscitation
2) Broad Spectrum ABX (Carbapenems)
3) NG tube and surgical consult (keep pt NPO)
</p>

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19
Q

<p>What is a Mallory-Weiss Tear?</p>

A

<p>Upper GI bleeding secondary to a longitudinal tear at the gastroesophageal junction</p>

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20
Q

<p>Risk factors for Mallory-Weiss Tear?</p>

A

<p>- Retching, Vomiting, Straining, Hiccups, Cough, Primal Scream Therapy, Blunt Abdominal trauma, CPR
- Hiatal Hernia </p>

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21
Q

<p>How does a Mallory-Weiss Tear present?</p>

A

<p>- 85% with Hematemesis

| - Other S/S relating to blood loss: Tachy, hypotension, orthostatic changes, shock </p>

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22
Q

<p>Ix for Mallory-Weiss Tear?</p>

A

<p>- Endoscopy, both for diagnosis and therapy

| </p>

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23
Q

<p>Tx of Mallory-Weiss Tear?</p>

A

<p>- Electrocautery

- Sclerosant injection (EtOH, Polidocanol)
- Argon Plasma coagulation
- Band ligation
- Hemoclip
- Balloon tamponade </p>

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24
Q

<p>What is costochondritis?</p>

A

<p>Inflammation of the costochondral or costosternal joints causing pain or tenderness</p>

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25
Q

<p>Presentation of costochondritis?</p>

A

<p>- Chest wall pain

- Often occurs at more than 1 sire
- Hx of repeated minor trauma
- Made worse with trunk movement, deep inspiration and or exersion
- Sharp nagging pain
- Severe but waxes and wanes</p>

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26
Q

<p>Management of costochondritis?</p>

A

<p>NSAIDS</p>

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27
Q

<p>What is herpes zoster?</p>

A

<p>Shingles, reactivation of Varicella zoster virus

| - Reactivation occurs secondary to some other source of immunosuppression </p>

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28
Q

<p>Complications of herpes zoster?</p>

A

<p>- CNS involvement (muscle weakness, CN palsies, diaphragmatic paralysis, neurogenic bladder, colonic pseudo-obstruction)

- Herpes zoster ophtalmicus
- Herpes zoster oticus</p>

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29
Q

<p>Clinical presentation of Herpes Zoster?</p>

A

<p>- Unilateral dermatomal eruption, occuring 3-5 days after onset of pain

- Paresthesia of effected dermatome
- vesicles, bullar, and pustules on erythmatous, edematous base
- 50% thoracic, 10-20% trigeminal, 10-20% cervical </p>

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30
Q

<p>What does a Tzanck Smear confirm?</p>

A

<p>Can confirm that a lesion is herpetic (Herpes Zoster) </p>

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31
Q

<p>Mangement of Herpes Zoster?</p>

A

<p>- Antiviral (ex. Famciclovir) for 7 days (must be started within 72hr to be of benefit)

- Analgesia (Narcotic, TCA, Anticonvulsant)
- TCA's shown to be most benefit with post herpetic neuralgia </p>

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32
Q

<p>What is a Pleural Effusion/Empyema </p>

A

<p>- Excess amount of fluid in the pleural space (normal is 25ml or under)

- Effusion - fluid
- Empyema - pus </p>

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33
Q

<p>What is the difference between a transudative and exudative fluid?</p>

A

<p>- Transudative: Due to alteration of systemic factors that affect the formation and absorption of pleural fluid. (^ capillary hydrostatic pressure, v plasma oncotic pressure)

- Exudative: Increased permability of pleural capillaries or lymphatic dysfunction.
- From inflammatory conditions </p>

34
Q

<p>What can cause transudative effusion?</p>

A

<p>CHF, Nephrotic syndrome, Peritoneal dialysis, cirrhosis, Cystic fibrosis </p>

35
Q

<p>What can cause exudative effusion?</p>

A

<p>PE (most often exudate), Pneumonia, TB, Malignancy </p>

36
Q

<p>Signs &amp;amp; Symptoms of Pleural Effusion?</p>

A

<p>- Often asymptomatic

- Progressive dyspnea
- Cough
- Pleuritic chest pain
- Fever (empyema)</p>

37
Q

<p>Which investigations are useful in DX Pleural Effusion?</p>

A

<p>- CXR

- Thoracentesis (analyze fluid)
- Pleural biopsy
- U/S
- CT scan</p>

38
Q

<p>How is pleural effusion/empyema managed?</p>

A

<p>- Treat underlying disease

- Therapeutic thoracentesis
- Tube thoracostomy </p>

39
Q

<p>What is a pneumothorax?</p>

A

<p>The presence of air or gas in the pleural cavity </p>

40
Q

<p>What are 5 different types of pneumothorax?</p>

A

<p>1) Spontaneous

2) Tension
3) Pneumomediastinum
4) Iatrogenic
5) Traumatic </p>

41
Q

<p>What type of person is at highest risk of having a spontaneous pneumo?</p>

A

<p>Primary: Tall, healthy young males

| Secondary: Those with underlying lung disease (Pneumonia, lung abscess, Cancer, emphysema) </p>

42
Q

<p>What can cause an iatrogenic pneumo?</p>

A

<p>In hospital, Central venous catheters, thoracentesis, mechanical ventilation </p>

43
Q

<p>What is a tension pneumothorax?</p>

A

<p>Occurs when injured tissue forms a one way valve. This lets air into pleural space on inspiration but does not allow it to leave on expiration</p>

44
Q

<p>How do you confirm a diagnosis of pneumothorax?</p>

A

<p>CXR </p>

45
Q

<p>How do you manage a primary spontaneous pneumo?</p>

A

<p>- under 15%, no Sx = O2 and watch

- under 15%, Sx present = needle aspiration
- over 15% = pigtail catheter with low suction </p>

46
Q

<p>How do you manage a secondary spontaneous pneumo</p>

A

<p>tube thoracostomy </p>

47
Q

<p>What is a pulmonary abscess?</p>

A

<p>Necrosis of the pulmonary tissue and formation of cavities containing necrotic debris or fluid
- Caused by microbial infection </p>

48
Q

<p>Are the most common causative organisms of pulmonary abscesses aerobic or anaerobic?</p>

A

<p>Anaerobic from the gingiva

| - Gingivitis and peridontal disease common in people with pulmonary abscess</p>

49
Q

<p>How does a pulmonary abscess typically present?</p>

A

<p>- Over a period of weeks-months

- Fever
- Productive cough
- Night sweats
- Anorexia
- Weight loss
- Hemoptysis
- Pleuritis </p>

50
Q

<p>What may you find on exam if the person has a pulmonary abscess?</p>

A

<p>- v Breath sounds

- Dullness on percussion
- Coarse inspiratory crackles
- Friction rubs
- Digital clubbing</p>

51
Q

<p>What investigations could be done to DX pulmonary abscess?</p>

A

<p>- CBC w diff (Leukocytosis, left shift)

- C&amp;amp;S and O&amp;amp;P sputum
- CXR </p>

52
Q

<p>What is a pulmonary embolism? </p>

A

<p>Obstruction of the pulmonary artery or one of its branches by and object that originated elsewhere in the body (Thrombus, tumour, air, fat) </p>

53
Q

<p>What are 3 risk factors for PE?</p>

A

<p>1) Stasis

2) Endothelial Cell Damage
- Post surgery
- Trauma
- Inflammation
3) Hypercoagulable State
- Malignancy
- CA treatment
- Exogenous estrogen
- Pregnancy and post partum
- Past DVT, PE
- Family Hx
- Nephrotic syndrome
- Age
- Coagulopathies </p>

54
Q

<p>What is Virchow's triad? Which condition is it associated with?</p>

A

<p>1) Venous stasis

2) Endothelial injury
3) Hypercoagulable state
* Associated with increased PE risk </p>

55
Q

<p>Where do most emboli that cause PE arise from?</p>

A

<p>Lower extremity proximal veins (Iliac, femoral, popliteal) </p>

56
Q

<p>What 3 pathological things happen during PE?</p>

A

<p>1) Pulmonary infarction

2) V/Q mismatch (dead space, ventilation intact but no perfusion)
3) Cardiovascular Compromise
- increase in vascular resistance due to obstruction and hypoxic vasoconstriction
- reduced left ventricular filling due to backflow in right, leads to lower cardiac output </p>

57
Q

<p>Symptoms of PE</p>

A

<p>- Dyspnea

- Pleuritic chest pain
- Cough
- DVT
- Orthopnea
- Wheezing
- Hemoptysis
- Tachypnea
- Tachycardia
- JVD
- Decreased breath sounds</p>

58
Q

<p>What lab test may support DX of PE?</p>

A

<p>- D-dimer (sensitive but poorly specific)

| - ABG (hypoxemia, resp. alkalosis) </p>

59
Q

What does Wells criteria evaluate?

A

Risk of Pulmonary Embolism

60
Q

95% of lung malignancy’s are classified as either: (2 categories)

A

1) Small cell lung cancer
2) Non-Small cell lung cancer
- squamous cell carcinoma
- adenocarcinoma
- large cell undifferentiated

61
Q

What are some risk factors for lung malignancy?

A
  • Smoking (accounts for 90% of lung CA)
  • Radiation Therapy
  • Environmental toxins
    • Asbestos
    • Radon
    • Polycyclic aromatic hydrocarbons
  • Pulmonary fibrosis
  • HIV
  • Genetics
  • Dietary
62
Q

Signs and Symptoms of lung malignancy?

A
  • Cough
  • Dyspnea
  • Chest pain
  • Hemoptysis
  • Clubbing
  • Constitutional Sx
63
Q

What investigations can be done to Dx lung CA?

A

Imaging: Xray, CT, Bone scan (look for mets)

  • Sputum cytology
  • Biopsy
64
Q

How is lung malignancy managed?

A
  • Surgery
  • Radiation
  • Chemotherapy
  • Palliation
65
Q

What is pneumonia?

A
  • An infection of the lung parenchyma

- Results in decreased gas exchange

66
Q

How can microbes be introduced to the respiratory tract? (3)

A
  • Aspiration (most common)
  • Direct inhalation
  • Hematogenous or embolic spread (from heart valves or venous clot)
67
Q

What are some risk factors for developing pneumonia?

A

1) Impaired lung defense
- poor cough/gag
- impaired mucociliary transport (CF)
- Immunosuppression (Steroids, chemo, HIV, CA, Transplant)
- Poor respiratory effort (Vent, COPD)
2) Increased risk of aspiration
- decreased LOC
- Obstruction

68
Q

What are common pathogens that cause community acquired pneumonia?

A 
Steptococcus pneumonia 
Moxarella cararrhalis 
Haemophilus influenzae 
Staphylococcus aureus
GAS
69
Q

Common nosocomial causes of Pneumonia

A

(Enterics)

  • E.coli, Pseudomonas aeruginosa
  • Staph aureus
70
Q

Common aspiration pneumonia causes

A

Oral anaerobes
- Bacteroides
Enterics
- E.coli, S. aureus

71
Q

SX of pneumonia?

A
  • SOB, Cough, Dyspnea
  • Chest pain, tachypnea, tachycardia, hemoptysis
  • Fever, chills, rigors, malaise
  • weightloss, v LOC in elderly
72
Q

Physical exam findings with pneumonia?

A
  • Decreased breath sounds
  • Crackles
  • Dullness on percussion
  • Bronchial sounds
73
Q

Which investigations can help your diagnosis of Pneumonia?

A
  • CBC w diff
  • Lytes (Na, K, Cl)
  • C&S sputum
  • CXR
  • Urea, Creatinine
  • Urinalysis
  • AST, ALT
  • Troponin, CK
74
Q

What is the CURB 65 criteria?

A 
For Pneumonia:
Confusion
Urea (>7mmol/L)
RR (30 or more) 
BP (Under 90/60mmHg)
Age over 65

1 point for each, score:
0 - Treat as outpatient
2 - Treat as in patient
3 + ICU admission

75
Q

How do you treat CAP?

A

1) No comorbidity
- Macrolide
2) Co-morbidity
- Levofloxacin
- Amoxiclav OR 2nd gen cephalosporin + macrolide
3) Aspiration suspected
- Amoxiclav + Macrolide

76
Q

How do you treat a hospitalized pt who develops pneumonia?

A
  • Levofloxicin or moxifloxicin

- second line: 2,3,4th gen cephalosporin + macrolide

77
Q

What is an aortic dissection?

A

Tear in the aortic intima that allows blood to dissect between the intima and media layers

78
Q

Risk factors for aortic dissection?

A
  • HTN
  • Atherosclerosis
  • Pre-existing aortic aneurism
  • Inflammatory disease with vasculitis
  • Collagen disorders (Marfan)
  • Bicuspid aortic valve, or replaced valve
  • Coarctation of aorta
  • Turner syndrome
  • Trauma
  • Cardiac Cath
  • Cocaine
  • Intense weight training
79
Q

Sx of Aortic dissection?

A
  • Sudden onset “tearing” chest pain
  • HTN
  • Asymmetric pulses
  • Syncope
  • Rupture to pleura (dyspnea, hemoptysis)
  • Tamponade (ruptures to pericardium)
80
Q

Investigations to help DX aortic dissection?

A
  • CBC, Trop, CK
  • BUN, Cr (renal artery involvement)
  • D-dimer
  • ECG
  • CXR, wide mediastinum, pleural effusion, tracheal deviation
  • CT/MRI
  • Trans esophageal echo (TEE)
81
Q

How do you manage a patient with aortic dissection?

A
  • Pain control
  • Reduce systolic BP (Labetolol and vasodilators)
  • Stop anticoagulants
  • Surgery may be required
  • Follow-up with imaging and blood pressure management

Module 203 (4 decks)

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