Unit 4 - Chest Pain Flashcards
somatic VS visceral pain
somatic: sharp, hot sensation that is well localized
visceral: difficult to describe sensations that are poorly localized and sensed remote from pathologic source
what are abdominal causes of chest pain?
cholecystitis, ectopic pregnancy
what are esophageal causes of chest pain?
rupture, spasm, GERD
what are cardiovascular causes of chest pain?
acute coronary syndromes (HTN, MI, angina), aortic dissection, pericarditis, valvular heart disease
what are respiratory causes of chest pain?
pulmonary embolism, pleural thrombosis, pneumonia, pleural effusion
recall the difference between specific VS sensitive tests
specific: positive in disease, few false positives
sensitive: negative if no disease, few false negatives
what ROS should you ask for chest pain?
- fever
- cough
- dyspnea (exertion, night time)
- extremity or trunk pain
what physical exam should you focus on for chest pain?
- HEENT
- neck (JVD, carotid pulses/bruits)
- breath sounds (crackles, rales)
- heart sounds
- pulses
- hands on chest, back, CVA, abdomen
- edema, venous cords, hair pattern (won’t grow if skin not perfused)
diagnostic studies for chest pain?
- Hct, chemistries, ultrasound angiography
- cardiac markers, D-dimer
- EKG
- CXR, CT
- stress testing
- angiography
what are aortic diseases?
- aneurysms (thoracic, abdominal)
- dissecting aneurysms
- traumatic ruptures
- intramural hematoma
- aortic ulcers
what is the etiology for an aortic dissection? what is it not?
- HTN
- CT disease
- pregnancy
- congenital cardiac abnormalities (Ebstein’s, bicuspid aortic calve, coarctation)
- aortic ulcers/crypts
probably not atherosclerosis, unlikely trauma
presentations for aortic dissection?
diverse:
- most commonly sharp chest pain radiating to back (85%)
- pain in back only
- pain commonly moves
- may radiate to neck, jaw, arms, lumbar area
- syncope (10-12%)
- neurologic defects common
- end organ ischemia
- may have spontaneous “cure”
physical exam of aortic dissection
- pulse defects (20%)
- aortic insufficiency
- tamponade
- altered mental status
- hemiplegia/paraplegia
- Horner’s syndrome
lab/imaging for aortic dissection
- EKG to rule out other causes
- CXR is most commonly abnormal in nonspecific manner
- mediastinal widening
- bulging aortic contour
- pleural effusions
- intimal Ca sign - advanced imaging: CT, angiogram, TEE sensitive and specific
what are pleural diseases?
- spontaneous pneumothorax
- pleural effusions
- pleurisy
how is pleura innervated?
somatically
explain the pathophysiology of pneumothorax
intrapleural pressure negative (-4 to -12 mmHg)
- lung tends to recoil away from chest wall
- surface tension of intrapleural fluid keeps lung inflated
- most patients have bleb that follows Laplace’s law (wall tension increases with radius)
- once air enters pleural space, it’s resorbed or causes pneumothorax
difference between spontaneous and tension pneumothorax?
S: primary, non-traumatic event (hemodynamic problem, no venous return)
-occurs mostly in thin, tall males
-associated with smoking, Marfan’s, alpha-1 antitrypsin deficiency, and changes in atmospheric pressure
T: increased intrapleural pressure above central venous pressure –> decreased venous return and hypotension
-if defect in pleural barrier acts as ball valve, air accumulates under pressure
pneumothorax and COPD
many patients are asymptomatic, but especially so with COPD
-high mortality with pneumothorax
presentation of pneumothorax? tension-type?
- pleuritic chest pain
- subacute course
- mild dyspnea
- breath sounds decreased unilaterally
- tympanitic hemithorax
- absent tactile fremitis
- Hamman’s crunch
for Tension type only (diagnosis made clinically)
- subcutaneous air
- tracheal deviation (can feel sternal notch)
- shock
- severe respiratory distress
- EMD
presentation of pleural effusion
- asymptomatic
- chest pain
- dyspnea
- decreased breath sounds
- dullness to percussion
- large effusions may show signs of mediastinal shift
what will CXR show for pleural effusion?
- 500 cc fluid necessary before CP angle blunting occurs on AP film, 200 cc for lateral film
- decubitis film shows if effusion is free-flowing
what is an empyema? treatment?
pneumonia complication
- most commonly in staph, strep, and G- organisms
- occurs after pneumonia, lung infarction, resection, or abdominal infection
- should be suspected if fever and pleural effusion
- treated with antibiotics and drainage
what is pericarditis?
positional pain that is sharp
- myocarditis, may have effusion
- viral, rheumatologic, uremic, traumatic, or post-MI
- has 4 stages of EKG progression
what is pneumomediastinum?
air comes from esophagus, trachea, bronchi, neck, or abdomen
- air dissects along vascular or bronchial planes centrally
- shows Hamman’s sign
- rarely causes compression and impairment of venous return
what are risk factors for thromboembolic emboli?
- trauma
- immobilization
- cancer
- surgery
- BCP
what are types of ischemic heart disease
- MI
- angina pectoris
- heart failure
silent ischemia is common too
what is a strong prognosticator for ischemic death?
CHF
pathophysiology of MI
- atheromas rupture and inflammation and acute clotting occurs; O2 delivery is interrupted
- myocardium becomes ischemic, then infarcted
- contractility is decreased
- dysrhythmias and disorders of automaticity more common in ischemic areas
what are causes of nonatheromatous MI?
- arteritis
- syphilis
- amyloidosis
- congenital anomalies of coronary artery
- toxins
- emboli
what does ST elevation show? differential?
heart injury
- MI
- early repolarization
- LV hypertrophy
- IVCD (paced rhythms)
- pericarditis/myocarditis
- hypothermia
- LV aneurysms
- 23% are “non-actionable” coronary arteries
what does ST depression show?
- reciprocal change, or nonspecific
- hypokalemia
- digoxin effect
- cor pulmonale
- LV hypertrophy
- IVCD (paced rhythms)
what does Q vave change show?
infarction
what do T-wave inversions show?
- pediatric patient
- IVCD (paced rhythms)
- any myocardial disease
- intracranial pathology
- cor pulmonale
- or anything else
what are markers for MI?
CK-MB, Troponin I/T
- myoglobin, myosin, inflammatory markers
- BNP excreted in response to atrial stretch
