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MSII Practice of Medicine > Unit 4 - Chest Pain > Flashcards

Unit 4 - Chest Pain Flashcards

1
Q

somatic VS visceral pain

A

somatic: sharp, hot sensation that is well localized
visceral: difficult to describe sensations that are poorly localized and sensed remote from pathologic source

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2
Q

what are abdominal causes of chest pain?

A

cholecystitis, ectopic pregnancy

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3
Q

what are esophageal causes of chest pain?

A

rupture, spasm, GERD

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4
Q

what are cardiovascular causes of chest pain?

A

acute coronary syndromes (HTN, MI, angina), aortic dissection, pericarditis, valvular heart disease

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5
Q

what are respiratory causes of chest pain?

A

pulmonary embolism, pleural thrombosis, pneumonia, pleural effusion

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6
Q

recall the difference between specific VS sensitive tests

A

specific: positive in disease, few false positives
sensitive: negative if no disease, few false negatives

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7
Q

what ROS should you ask for chest pain?

A
  • fever
  • cough
  • dyspnea (exertion, night time)
  • extremity or trunk pain
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8
Q

what physical exam should you focus on for chest pain?

A
  • 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)
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9
Q

diagnostic studies for chest pain?

A
  • Hct, chemistries, ultrasound angiography
  • cardiac markers, D-dimer
  • EKG
  • CXR, CT
  • stress testing
  • angiography
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10
Q

what are aortic diseases?

A
  1. aneurysms (thoracic, abdominal)
  2. dissecting aneurysms
  3. traumatic ruptures
  4. intramural hematoma
  5. aortic ulcers
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11
Q

what is the etiology for an aortic dissection? what is it not?

A
  • HTN
  • CT disease
  • pregnancy
  • congenital cardiac abnormalities (Ebstein’s, bicuspid aortic calve, coarctation)
  • aortic ulcers/crypts

probably not atherosclerosis, unlikely trauma

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12
Q

presentations for aortic dissection?

A

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”
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13
Q

physical exam of aortic dissection

A
  • pulse defects (20%)
  • aortic insufficiency
  • tamponade
  • altered mental status
  • hemiplegia/paraplegia
  • Horner’s syndrome
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14
Q

lab/imaging for aortic dissection

A
  1. EKG to rule out other causes
  2. CXR is most commonly abnormal in nonspecific manner
    - mediastinal widening
    - bulging aortic contour
    - pleural effusions
    - intimal Ca sign
  3. advanced imaging: CT, angiogram, TEE sensitive and specific
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15
Q

what are pleural diseases?

A
  • spontaneous pneumothorax
  • pleural effusions
  • pleurisy
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16
Q

how is pleura innervated?

A

somatically

17
Q

explain the pathophysiology of pneumothorax

A

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
18
Q

difference between spontaneous and tension pneumothorax?

A

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

19
Q

pneumothorax and COPD

A

many patients are asymptomatic, but especially so with COPD

-high mortality with pneumothorax

20
Q

presentation of pneumothorax? tension-type?

A
  • 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
21
Q

presentation of pleural effusion

A
  • asymptomatic
  • chest pain
  • dyspnea
  • decreased breath sounds
  • dullness to percussion
  • large effusions may show signs of mediastinal shift
22
Q

what will CXR show for pleural effusion?

A
  • 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
23
Q

what is an empyema? treatment?

A

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
24
Q

what is pericarditis?

A

positional pain that is sharp

  • myocarditis, may have effusion
  • viral, rheumatologic, uremic, traumatic, or post-MI
  • has 4 stages of EKG progression
25
Q

what is pneumomediastinum?

A

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
26
Q

what are risk factors for thromboembolic emboli?

A
  • trauma
  • immobilization
  • cancer
  • surgery
  • BCP
27
Q

what are types of ischemic heart disease

A
  • MI
  • angina pectoris
  • heart failure

silent ischemia is common too

28
Q

what is a strong prognosticator for ischemic death?

A

CHF

29
Q

pathophysiology of MI

A
  • 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
30
Q

what are causes of nonatheromatous MI?

A
  • arteritis
  • syphilis
  • amyloidosis
  • congenital anomalies of coronary artery
  • toxins
  • emboli
31
Q

what does ST elevation show? differential?

A

heart injury

  • MI
  • early repolarization
  • LV hypertrophy
  • IVCD (paced rhythms)
  • pericarditis/myocarditis
  • hypothermia
  • LV aneurysms
  • 23% are “non-actionable” coronary arteries
32
Q

what does ST depression show?

A
  • reciprocal change, or nonspecific
  • hypokalemia
  • digoxin effect
  • cor pulmonale
  • LV hypertrophy
  • IVCD (paced rhythms)
33
Q

what does Q vave change show?

A

infarction

34
Q

what do T-wave inversions show?

A
  • pediatric patient
  • IVCD (paced rhythms)
  • any myocardial disease
  • intracranial pathology
  • cor pulmonale
  • or anything else
35
Q

what are markers for MI?

A

CK-MB, Troponin I/T

  • myoglobin, myosin, inflammatory markers
  • BNP excreted in response to atrial stretch

MSII Practice of Medicine (13 decks)

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