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Block 1 Year 3 > Week 5 - Chest Pain > Flashcards

Week 5 - Chest Pain Flashcards

1
Q

What is atherosclerosis ?

A

Chronic inflammatory process triggered by accumulation of cholesterol-containing, low-density lipoproteins (LDL) in the arterial wall

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2
Q

What is the most likely diagnosis of…

“Sudden onset pleuritic pain either left or right sided with associated dyspnoea and syncope” ??

A

Pneumothorax

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3
Q

What is the most likely diagnosis of…

“Pain typically persistent (days or longer), worsened with passive and active motion and sometimes reproducible chest tenderness” ?

A

Musculoskeletal pain

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4
Q

What is the most likely diagnosis of…

“Exertional pain/discomfort in the centre or left side of chest, throat, neck or jaw, relieved by rest or GTN within a few minutes. May radiate to neck, jaw or left arm. Sometimes there may not be any pain but breathlessness” ?

A

Angina

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5
Q

What is the most likely diagnosis of…

“Constant or intermittent central pleuritic sharp pain often aggravated by position (classically worse lying down, and relieved by sitting or leaning forward)” ?

A

Pericarditis

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6
Q

What is the most likely diagnosis of…

“Sudden onset pleuritic pain with associated dyspnoea and tachycardia. Sometimes mild fever, haemoptysis and syncope” ?

A

Pulmonary Embolism

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7
Q

What is the most likely diagnosis of…

“Recurrent, vague epigastric discomfort, that is relieved by food, antacids, or both” ?

A

Peptic ulcer disease

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8
Q

List some cardiovascular conditions that would cause central chest pain …

A
  • angina
  • acute coronary syndrome
  • pericarditis
  • aortic dissection
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9
Q

List some respiratory conditions that would cause central chest pain …

A
  • PE
  • Pleurisy
  • Pneumonia
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10
Q

List some musculoskeletal conditions that would cause central chest pain …

A
  • rib fracture
  • muscle injury
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11
Q

Name a skin condition that would cause central chest pain …

A

Shingles

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12
Q

List some gastrointestinal conditions that would cause central chest pain …

A
  • peptic ulcer disease
  • oesophageal spasm
  • oesophageal rupture
  • gall stones
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13
Q

What are the conditions included under the umbrella term of Acute Coronary Syndrome ?

A
  • ST elevation MI (STEMI)
  • non ST elevation MI (NSTEMI)
  • unstable angina
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14
Q

What are the symptoms of Acute Coronary Syndrome ?

this includes: STEMI, NSTEMI, unstable angina

A
  • acute, crushing pain
  • pain radiation to jaw or arm
  • exertional pain, relieved by rest
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15
Q

What are the signs of Acute Coronary Syndrome ?

this includes: STEMI, NSTEMI, unstable angina

A
  • sinus tachycardia
  • a new murmur (often mitral regurgitation = pan-systolic)
  • Xanthelasma
  • tar staining on fingers
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16
Q

What are the risk factors for Acute Coronary Syndrome ?

this includes: STEMI, NSTEMI, unstable angina

A
  • hypertension
  • hypercholesterolaemia
  • diabetes
  • cigarette smoking
  • lack of physical activity
  • obesity/overweight
  • poor diet
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17
Q

What are the symptoms of stable angina ?

A
  • exertional pain/discomfort (central/left sided in chest, throat, neck, jaw)
  • relieved by rest or GTN within a few mins
  • radiate to neck, jaw, left arm
  • sometimes no pain, but breathlessness
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18
Q

What are the signs of stable angina ?

A

Examination usually normal except indication of risk factors e.g tar staining, xanthelasma…

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19
Q

What are the risk factors for stable angina ?

A
  • hypertension
  • hypercholesterolaemia
  • diabetes
  • cigarette smoking
  • lack of physical activity
  • obesity/overweight
  • poor diet
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20
Q

What are the symptoms of thoracic aortic dissection ?

A
  • sudden, tearing pain radiating to back
  • some patients have syncope, stroke, leg ischaemia
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21
Q

What are the signs of thoracic aortic dissection ?

A
  • pulses paradoxus
  • different BP in both arms
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22
Q

What are the risk factors for a thoracic aortic dissection ?

A
  • hypertension
  • known aortic aneurysm
  • bicuspid aortic valve
  • Marfan’s syndrome
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23
Q

What are the symptoms of myocarditis ?

A
  • fever
  • dyspnoea
  • fatigue
  • chest pain (if myopericarditis)
  • maybe pleuritic chest pain
  • recent viral/other infection
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24
Q

What are the signs of myocarditis ?

A
  • fever
  • tachycardia
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25
Q

What are the risk factors for myocarditis ?

A

Recent viral illness

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26
Q

What are the symptoms of pericarditis ?

A
  • constant or intermittent sharp chest pain
  • pain often aggravated by breathing or position
  • classically worse when lying down, better sitting or lent forwards
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27
Q

What are the signs of pericarditis ?

A
  • tachycardia
  • pericardial rub
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28
Q

What are the risk factors for pericarditis ?

A

Recent viral illness

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29
Q

What are the symptoms of PE ?

A
  • sudden onset pleuritic pain, associated with tachycardia and SOB
  • sometimes mild fever, haemoptysis and syncope
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30
Q

What are the signs of PE ?

A
  • tachycardia
  • swollen leg (unilateral, red, sore and hot)
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31
Q

What are the risk factors for PE ?

A
  • immobility for long time period
  • long haul flight
  • inherited blood clotting disorders
  • recent surgery or broken bone injury (risks are higher after both of these)
  • active/history of cancer
  • acute medical illness (DKA, sepsis)
  • pregnancy
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32
Q

What are the symptoms of tension pneumothorax ?

A
  • significant SOB
  • hypotension
  • raised JVP
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33
Q

What are the signs of tension pneumothorax ?

A
  • tracheal deviation
  • unilateral diminished breath sounds
  • hyperresonance on percussion
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34
Q

What are the risk factors for tension pneumothorax ?

A
  • male
  • smoking
  • lung disease (e.g emphysema)
  • marfan’s syndrome
  • genetic
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35
Q

What are the symptoms of pneumonia ?

A
  • pleuritic chest pain
  • fever
  • productive cough
  • purulent sputum
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36
Q

What are the signs of pneumonia ?

A
  • bronchial breathing
  • crepitations
  • reduced air entry
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37
Q

What are the risk factors for pneumonia ?

A
  • older age
  • infective contacts
  • underlying chronic lung disease
  • immunosuppression
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38
Q

What are the symptoms of pleurisy ?

A
  • pleuritic chest pain (exacerbated by cough)
  • may have preceding pneumonia, PE or viral resp infection
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39
Q

What are the signs of pleurisy ?

A

Pleural rub

40
Q

What are the risk factors for pleurisy ?

A

Recent infection

41
Q

What are the symptoms of oesophageal rupture ?

A

Sudden, severe pain following vomiting or medical instrumentation (e.g imagining, feeding tubes etc)

42
Q

What are the signs of oesophageal rupture ?

A

severe epigastric pain with guarding and rigidity

43
Q

What are the risk factors for oesophageal rupture ?

A
  • gastroscopy /imagining with throat entry
  • transoesophageal echocardiography
  • catheter ablation for AF
44
Q

What are the symptoms of peptic ulcer disease ?

A
  • recurrent vague epigastric discomfort
  • relieved by food, antacids or both
45
Q

What are the signs of peptic ulcer disease ?

A

epigastric discomfort

46
Q

What are the risk factors for peptic ulcer disease ?

A
  • hypertension
  • hypercholesterolaemia
  • diabetes
  • cigarette smoking
  • lack of physical activity
  • obesity/overweight
  • poor diet
47
Q

What are the symptoms of pancreatitis ?

A
  • epigastric pain worse when lying down, relieved leaning forward
  • vomiting
  • upper abdominal tenderness
48
Q

What are the signs of pancreatitis ?

A
  • epigastric pain
  • jaundice
49
Q

What are the shriek factors for pancreatitis ?

A
  • high alcohol intake
  • raised BMI
  • female
50
Q

What are the symptoms of GORD ?

A
  • recurrent burning pain
  • pain radiating from epigastrium to throat
  • Exacerbated by lying/bending down
  • Relieved by antacids
51
Q

What are the signs of GORD ?

A
  • mild epigastric tenderness
52
Q

What are the risk factors for GORD ?

A
  • raised BMI
  • stress/anxiety
  • smoking
  • triggers: coffee, chocolates
53
Q

What are the symptoms of MSK pain ?

A
  • often suggested by history
  • persistent pain, worsened with passive and active motion
54
Q

What are the signs of MSK pain ?

A

Diffuse of focal tenderness

55
Q

What are the risk factors for MSK pain ?

A
  • recent injury
  • heavy lifting
  • osteoporosis
56
Q

What are the symptoms of shingles ?

A
  • sharp, band-like in thorax unilaterally
  • classic linear, vesicular rash
  • pain pain may precede rash by several days
57
Q

What are the signs of shingles ?

A

Rash on chest with vesicles

58
Q

What are the risk factors for shingles ?

A
  • immunosuppression
  • older age
59
Q

What is a normal heart rate ?

A

Between 60-100 bpm

60
Q

What are the risk factors for coronary heart disease (CHD) ?

A
  • age
  • ethnicity
  • male gender
  • family history
  • smoking
  • obesity
  • exercise
  • diabetes
  • hyperlipidaemia
  • hypertension
  • inflammatory disease
61
Q

Is the mortality risk following an MI higher in men or women ?

A

Women

due to biases and inequalities of treatment

62
Q

Why are women more likely to die after an MI than men ?

A

inequalities and biases

  • less likely to have risk factors recorded
  • less likely to receive aspirin
  • less likely to undergo investigation
  • underepresentation in clinical trials
  • women present slightly differently and it isn’t known as well as male signs of MI
63
Q

What % of people survive a heart attack ?

A

70%

64
Q

What is involved in clinical assessment for stable angina ?

A
  • history of chest pain
  • risk factors
  • OBs/NEWS
  • 12 lead ECG
  • bloods (inc. diabetes screening)
65
Q

What are the diagnostic features of typical angina chest pain ?

A
  • constricting discomfort in chest, shoulders, neck and arms
  • worse on exertion
  • relieved by GTN or rest in 5 mins
66
Q

Why is stable angina exertional pain ?

A
  • atheroma narrows coronary artery/vessels
  • on exertion, myocardial demand rises
  • supply cannot meet demand
67
Q

What is the first investigation for all patients experiencing chest pain for longer than 15 mins ?

A

12 lead ECG to exclude ST elevation

68
Q

What is the next investigation after an ECG for patients with ongoing chest pain and no findings of ST elevation on the ECG ?

A

Troponin testing

69
Q

After an ECG showing no ST elevation, what is indicated if the 6hr troponin test comes back…
A) elevated ?
B) not elevated ?

A

Elevated = NSTEMI
Not elevated = Unstable Angina

70
Q

What is the immediate investigation plan for patients with acute chest pain ?

A
  1. 12 lead ECG (looking for ST elevation)
  2. 6hr troponin test (if no elevation found)
71
Q

Which type of troponins are looked for in the 6hr troponin test ?

A

Troponin T
Troponin I

72
Q

What happens to a patient found to have no ST elevation, but raised Troponin T or I ?

A

considered high risk

  • admitted to coronary care unit
  • undergo angiography and/or angioplasty
73
Q

What tool is used to gauge a patients risk of cardiovascular events in the next 10 years ?

A

QRISK3 score

74
Q

What information does the QRISK3 score need in order to calculate a patients risk of cardiovascular events within 10 years?

A
  • age
  • gender
  • smoking status
  • history of diabetes, hypertension
  • family history of cardiovascular problems
  • physical exercise status
  • diet
  • BMI
  • cholesterol

As well as…
- migraine
- chronic kidney disease (inc. stage 3 CKD)
- corticosteroids
- SLE
- atypical antipsychotics
- severe mental illness
- erectile dysfunction
- systolic BP variability

75
Q

What does GTN stand for?

A

Glyceryl trinitrate (spray)

76
Q

Can a normal ECG rule out acute coronary syndrome ?

A

No !

NSTEMI and unstable angina can often have a normal ECG, as the pain has subsided by the time it’s performed

77
Q

What test is required to rule out acute coronary syndrome in patients with chest pain but a normal ECG ?

A

Cardiac Troponin test

78
Q

What troponin result would indicate MI ?

A

A 50% rise or fall in troponin within 3-6 hours after the onset of chest pain

79
Q

What is the treatment for an acute STEMI ?

A

Dual anticoagulant therapy of aspirin paired with:
- prasugrel if not already taking oral anticoagulant (offer ticagrelor or clopidogrel as alternatives if the patient has a high risk of bleeding)
- clopidogrel if already taking an anticoagulant

80
Q

Are STEMIs or NSTEMIs more common ?

A

NSTEMI

81
Q

What treatment medications are offered to patients following an MI ?

A
  • ACE inhibitors
  • dual antiplatelet therapy (aspirin + another anticoag e.g clopidogrel)
  • beta blockers
  • statins
82
Q

What might acute chest pain paired with breathlessness indicate ?

A

A respiratory cause e.g PE, Pneumothorax

83
Q

What might acute chest pain paired with nausea, vomiting, pallor and sweating indicate ?

A

Acute MI

84
Q

What might acute chest pain paired with a productive cough indicate ?

A
  • Chest infection e.g pneumonia
  • Pleurisy
85
Q

What might acute chest pain paired with fever and non-specific viral symptoms indicate ?

A
  • pericarditis
  • myocarditis
86
Q

What might acute chest pain paired with fever, night sweats and weight loss indicate ?

A

Malignancy with lung or bone metastasis causing chest pain

87
Q

What might acute chest pain paired with palpitations indicate ?

A

Arrhythmia

88
Q

What might acute chest pain paired with dizziness and syncope indicate ?

A

Serious acute conditions

  • tachyarrythmias
  • MI
  • aortic dissection
  • PE
  • tension pneumothorax

dizziness and syncope are red flag symptoms

89
Q

How is the pain described in most patients with an aortic dissection ?

A
  • from chest, migrating to the back
  • from abdomen, migrating to one or more limbs or the neck
  • severe
  • not affected by exertion, movement or position
90
Q

What are the most common clinical signs for aortic dissection ?

A
  • pulsus paradoxus
  • distended neck veins
  • muffled heart sounds
  • pulse deficits (a difference of 20mmHg or more in BP between left and right arms)
91
Q

What are some risk factors for aortic dissection ?

A
  • hypertension
  • atherosclerosis
  • aortopathies e.g bicuspid aortic valve disease
  • connective tissue disorders
  • hereditary conditions e.g Marfan’s
92
Q

What is the first line investigation if aortic dissection is suspected ?

A

Urgent contrast thoracic aortogram

93
Q

What is type A aortic dissection ?

A

Dissection involving the ascending aorta

94
Q

What is type B aortic dissection ?

A

Dissection not including the ascending aorta

95
Q

What is the immediate treatment for type A aortic dissection ?

A

Surgery

96
Q

What is the immediate management of type B aortic dissection ?

A

Admitted for urgent BP control and monitoring in a coronary high dependency care unit

Block 1 Year 3 (7 decks)

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