study guide #4 Flashcards
list the common causes of non-cardiac chest pain
- peptic ulcer disease -PPI & abt
- gastroesophogeal reflex disease -give trial dose of PPI for 1-2 mos
- CAD- EKG & check for lipids
- costochondritis -heat, NSAIDs reassurance self limiting, avoid over use, take NSAIDs with food. F/U rtc if symptoms worsen
- acute anxiety
- MS pain
life threaten cardiac chest pain
**Aortic Dissection: tear in aorta- sudden tear pain located in ant. or post. may radiate to arms/leg/ back, may have hypotension
**pulmonary embolism: able to localize painful area over lung s/x dyspnea apprehension, hemoptysis gripping or stabbing pain that is mod-severe and may increase with deep breaths, may radiate to neck or shoulder, crackles over site
risk factor: bed rest, orthopedic surgery
explain life span considerations in determining the dx when pt. has chest pain
after cardiac & life threatening non-cardiac conditions are excluded, the pt’s age is often the most important factor in determining the dx.
- -> younger pts chest pain generally caused by more benign underlying conditions
- ->older pts with more risk factors and comorbid conditions are more likely to have serious causes of their chest pains
- ->regardless of age cardiac & life threatening noncardiac complications should be rule out first
- *under 40 : normal EKG sufficient to r/o cardiac chest pain
- *older than 40 or risk factors : cardiac enzyme, stress test, coronary angiography may be necessary
- *risk smoking, DM, obesity stress hyperlipidemia
- *women: ECG stress test is less reliable as dx, more invasive image based stress tests are more accurate
discuss risk factors for coronary artery disease
male >45 y.o female >55 family hx of premature coronary heart disease cigarette smoking hypertension low HDL 130
when should the patient with chest pain be sent to ED ?
NON-LOCALIZED pain
lasting >20 minutes
associated with diaphoresis dyspnea n/v dizziness radiation to neck jaw shoulder or arm
life threatening condition : MI
- -> sudden onset not relieved by rest or nitro
- ->associated symptoms
life threatening condition: Aortic dissection
- -> sudden tearing pain located in the anterior or posterior chest
- -> may radiate to arm, legs, abd, or back
life threatening condition PE
- -> able to point to area over the lung
- ->dyspnea
- -> apprehension
- -> hemoptysis
- -> gripping or stabbing pain of moderate or severe intensity that may increase with deep breathing
- -> may radiate to neck or shoulder
- ->bed rest and orthopedic surgery are risk factors
- -> women older adults and DM pts may present with atypical symptoms
how might a pt. describe angina?
demonstrates characteristic symptoms that occur with predictable frequency severity duration and provocation
the symptoms occur with exertion, are relieved by rest or no more than one nitro tablet and generally last for 1-3 minutes.
angina
often occurs with nausea, fatigue, SOB, sweating. may be stable or unstable. stable goes away unstable stays >30 minutes. stable is usually with exertion but unable may be with rest and different from usual pattern
classic angina
Classic: the chest pain & discomfort common with angina may be described as pressure, squeezing fullness or pain in the center of your chest. some people with angina symptoms describe angina as feeling like a vise is squeezing their chest or feeling like heavy weight has been placed on their chest
woman experience angina
different from classic symptom
nausea SOB abdominal pain or extreme fatigue, with or w/o chest pain.
may feel discomfort in the neck jaw or back or STABBING PAIN instead of the more typical chest pressure.
this lead to delays tx*
- Describe the physical examination findings when your patient has sustained an MI. (Remember that about 90% of the diagnosis of an acute coronary event is made from the patient’s history
Sx: sudden onset of non-localized pressure/pain, constrictive (not a sharp stabbing pain), not relieved with nitro, associated sx (cool, pale, moist skin)
MI -General appearance
-grimacing, diaphoresis, cyanosis, pallor, tachypnea
MI - VS
B/P may be elevated in MI
MI - Heart sounds
- -Auscultate
- a new transient, paradoxical S2 during pain can indicate coronary ischemia
- S4 (atrial gallop) indicates stressed heart which can result from MI hypertension or CAD
- irregular heart rhythms are often heard during
MI-Examine Extremities
- peripheral cyanosis can indicate hypoxia
- lower extremity edema may indicate CHF
Which is more predictive of an acute MI – EKG with ST elevations or history and presenting symptoms?
- The history and presenting symptoms is the short answer. A normal ECG can rule out MI in patients below 40. However, this is not the case in older patients (pg 435). If a patient presents with a hx and physical exam consistent with MI and has a normal ECG, further testing is definitely indicated (as noted in previous response). Essentially, the history and physical trumps the ECG
- A normal ECG in a patient younger than 40 yo is generally sufficient to rule out a cardiac problem. What will patients older than this and/or with risk factors require in terms of diagnostic testing? Will this vary with gender?
Cardiac Workup:
- Cardiac troponins (I&T): Rise within 2-4 hrs post MI and remain elevated 7-10 days
- Serum cardiac enzymes (CPK): Rise 4-8 hrs after MI and return to normal 48-72 hours
- SGOT and LDH: elevated later and not indicators of acute MI
- Elevated leukocytes, ESR: non specific indicators
- EKG: does not completely rule out, but decreases odds by 70-90%
- ECG
- Labs- CKMB, troponins, myoglobin
- Stress Test
- Echocardiogram
- Testing will vary with gender. False positive results in women more likely occur with many of the cardiac tests and speculation suggests it’s because of women’s lower hematocrit level and higher circulating estrogen level.
- Stress echocardiography may prove a more accurate method of noninvasice CAD testing in women
Pulmonary embolus
dyspnea, hemoptysis, sharp pain
- decreased breath sounds - orthopedic surgery is a risk factor
PE
What diagnostic tests are needed? Give your rationale.
-according to a discussion posting you would refer to the hospital STAT and they would run tests
Costochondritis-
inflammation of the rib cartilage. Pain with palpation over cartilage between ribs and sternum
Costochondritis H & P , management
• often is history of recent
o illness with coughing
o strenuous exercise
• precipitating and relieving factors - usually pain affected by movement or inspiration
• sometimes trauma, strain, or relation to emotional stress
• any other joints involved
- application of heat and NSAIDs*
- Condition is self-limiting, avoid overuse and trauma, take NSAIDs with food
- Return if condition worsens or no improvement
peptic ulcer disease
- episodic gnawing or burning epigastric pain
- pain occurring 2-5 hours after meal or on empty stomach
- nocturnal pain relieved by food, antacids, or antisecretory agents
- it is usually related to meals
MI management
ASA, Nitrates, O2, beta blockers
Define dizziness and vertigo
Vertigo: condition that causes dizziness
Dizziness: is a symptom, sx of vertigo, sensation of spinning, tilting, or moving back and forth of ones self or the environment
-less than half of pts complaining of dizziness actually have vertigo
Differentiate vertigo, disequalibrium and presyncope/syncope.
Disequilibrium: loss of balance and lack of coordination, may accompany dizziness
Presyncope/syncope: feeling like you’re about to faint/faint
vertigo causes : vestibular
Vestibular: imbalance in vestibular system
- –>Peripheral: problems of inner ear or cranial nerve 8, most common type
1. Benign positional paroxysmal vertigo
2. Meniere’s disease
3. Vestibular neuronitis - –> Central: includes brainstem ischemia and infarction and demylenating diseases such as MS (much less common) usually accompanied with other brainstem deficits. Can be associated with sx such as diplopia (double vision), and motor deficits
vertigo causes: Non vestibular:
other causes include systemic viral or bacterial infections causing postural hypotension; metabolic issues such as hypo/hyperglycemia, electrolyte disturbance, anemia; drugs (hypnotics, ETOH, antihypertensive’s, tranquilizers, analgesics)
Verstibular neuronitis
Sarah V., a 55 year old waitress, comes to clinic complaining of dizziness and vertigo that began as she was recovering from an upper respiratory infection. She is very nauseated and tells the provider that she vomited this morning.
management for vestibular neuronitis
bed rest while symptoms are severe
- antibiotics if it is associated with a bacterial infection
- Methylprednisone
List the vestibular suppressants (pharmacological) that may be used for vertigo and associated nausea, vomiting, and anxiety. Which one is the drug of choice? Can it be used in pregnancy?
Methylprednisolone can be given once daily for 22 days
- Pregnancy use is class C, so it shouldn’t be recommended in pregnancy
- symptom relief with anticholinergics, antihistamines, long acting benzodiazepines, or antiemetics
- **antivert and antiemetics can be helpful during an attack but should be stopped after 3 days since continuing may slow recovery
- symptoms resolve spontaneously in 3-6 weeks with no sequelea
education for pt with vestibular neuronitis
- slowly change positions
- adequate hydration and safety
- avoid driving and operating heavy equipment while taking sedatives or antihistamines
when to consult with otolaryngologist for vestibular neuronitis
consult if diagnosis is unclear, the bacterial infection is severe, or symptoms do not resolve within 4-6 weeks
F/U eval should be scheduled to reassess the pt. and to ensure that vertigo is resolving
differentiate vestibular neuronitis from Meniere’s disease
hearing is not affected in vestibular neuronitis whereas hearing loss is experienced in Meniere’s
Benign paroxysmal positional vertigo (BPPV)
head trauma
- prior viral inner ear infection
- symptoms intermittent
- nausea or imbalance is not typical
Hallpike Dix maneuver
sitting then quickly lay back and put head below exam table. Vestibular peripheral issues (intense vertigo, 3-10 second delay in nystagmus, lessens with repetition, in a fixed direction) central issues (mild vertigo, immediate nystagmus in any changing positions, does not fatigue with repetition)
- How would you manage this condition, including patient education. What is a complication or concern for someone with BPPV?
may resolve in a few days or weeks w/o any treatment
- referral for vestibular PT may shorten recovery time
- epleys maneuver- can be taught to do at home, especially if recurrence (50% of pts)
- meclizine (antivert) can be used but is not as effective as exercises and do not suppress acute attacks-pregnancy cat B
- acute vertigo can be frightening so information about evaluation, prognosis, and treatment options will help alleviate fears of a more serious condition
- emphasize that the most effective treatment (vestibular therapy and exercises) may initially cause increased symptoms, but the treatment must continue for the symptoms to subside.
- vestibular disorders website has helpful info for pts and providers
complications of BPPV
Complication of BPPV are indirect such as falling and the risk of inherent self imposed decreased mobility. Safety issues should be addressed r/t driving with head turning
follow up for BPPV
- referral to PT should be first line, rather than medication treatment
- if BPPV is likely the diagnosis but symptoms are refractory to liberatory maneuvers refer to a specialist
- RTC if no improvement
Meniere’s Disease
diagnostic criteria for Meniere’s disease.
- 2 episodes
- last at least 20 minutes each
- accompanied by hearing loss, tinnitus, or aural fullness
Weber and a Rinne test
- Weber- lateralization to unaffected with sensorineural hearing loss
- Rinne (AC:BC) with sensorineural loss, BC and AC are both reduced but ratio remains the same
management for Meniere
- refer to otolaryngologist for testing and management
- bed rest during an attack
- may recommend decreasing NA, caffeine, alcohol and tobacco but benefit unclear
- antivert and antiemetics with severe symptoms may help
- diuretics may reduce severity of attacks
Meningitis
History should include exposures
- travel, food consumption, sexual practices, drug use - History of infectious disease - immunocompromised
Kernig’s and Brudinski’s signs.
Temp, pulse and RR
Signs of meningeal irritation
-brudinski’s sign- hip and knee flexion with the neck flexed
-Kernig’s sign- inability to fully extend the legs
brudinski sign (appearance of involuntary lifting of the legs when lifting a patient’s head off the examining couch, with the patient lying supine)
kernig sign (positive when the thigh is bent at the hip and knee at 90 degree angles, and subsequent extension in the knee is painful-leading to resistance, pos in hemorage or men)
Assess for Altered LOC (confusion, lethargy, stupor, coma)
Assess Cranial nerves (may see diplopia, deafness, facial weakness, pupil abnormalities)
manage Meningitis
-S/S indicate possible meningitis, immediate referral to a neurologist or ED
