January 13, 2016 - SG2 - Chest Discomfort II Flashcards

1
Q

DDx for Chest Discomfort

A

Falls into one of three broad categories…

  1. Cardiac
  2. Pulmonary
  3. Other
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2
Q

DDx for Pulmonary Chest Discomfort

A

The pleura may be involved - pneumothorax, pleurisy, or a tension pneumothorax*

The parenchyma may be involved - pneumonia, or a neospasm

The vasculature may be involved - pulmonary embolism*

* = may kill you

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3
Q

DDx for Cardiac Chest Discomfort

A

Could be pericardial - pericarditis, pericardial effusion, pericardial constriction, or a tamponade*

Could be myocardial - systolic dysfunction, diastolic dysfunction, cardiomyopathies, or myocarditis

Could be valvular - regurgitation, stenosis, or sub-valvular disease

Could be vascular - stable angina, acute coronary syndrome*, or aortic dissection*

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4
Q

DDx for “Other” Chest Pain

A

Could be gastrointestinal - GERD, cholecystitis, peptic ulcer disease, pancreatitis, esophageal spasm, or esophageal perforation*

Could be MSK - trauma

Could be neurologic - anxiety/panic, HZV / post-herpatic neuralgia, spinal radiculopathy

* = could kill you

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5
Q

Acute Coronary Syndrome - Profile

A

History - crushing, retrosternal, brief, radiation to the jaw/arms. Often has coronary risk factors

Physical Exam - May show S4, paradoxical splitting of S2, MR murmur

Labs - Troponin T (best marker of injury)

ECG - ST elevation or depression, T-wave inversion. Q-waves late.

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6
Q

Pericarditis - Profile

A

History - Pleuritic pain, worse when supine, better when sitting

Physical Exam - maybe a triphasic rub

Labs - none

ECG - diffuse ST elevation, PR depression

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7
Q

Aortic Dissection - Profile

A

History - sudden onset “ripping” pain to the back. History of hypertension or Marfan’s syndrome

Physical exam - differential blood pressure in both arms

Labs - no specific

ECG - If dissect RCA, inferior (II, III, AVF) ST elevation

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8
Q

Pulmonary Embolism - Profile

A

History - abrupt pleuritic chest pain, dyspnea. History of DVT and risk factors (Virchow’s Triad)

Physical Exam - Depends on size. Possible DVT signs and symptoms. Elevated JVP.

Labs- D-Dimer present (good negative predictive value)

ECG - sinus tachycardia

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9
Q

Pneumonia - Profile

A

History - fever, cough, sputum

Physical Exam - tachypnea, fever, tactile fremitus, bronchial breathing, crackles, egophony, +/- effusion signs

Labs - CXR: air bronchograms, silhouette sign, effusions

ECG - sinus tachycardia

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10
Q

Pneumothorax - Profile

A

History - sudden onset of sharp chest pain, dyspnea. Risk factor: asthma, Marfan’s syndrome, previous pneumothorax

Physical Exam - decreased chest excursion on the affected side, diminished breath sounds, hyperresonant to percussion. Tracheal deviation away if tension.

Labs - CXR: “pleural line”

ECG - sinus tachycardia

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11
Q

Well’s Score

A

Clinical probability for a pulmonary embolism.

Clinical signs and symptoms of DVT - 3

Tachycardia - 1.5

Immobilization for >3 days or surgery in last 4 weeks - 1.5

Previous PE or DVT - 1.5

Hemoptysis - 1

Cancer - 1

PE more likely than anything else - 3

<2 = low probability

2-6 = moderate probability

>6 = high probability

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12
Q

Slightly Elevated Troponin T

A

Not necessarily indicitive of a heart attack, as any damage can cause the release of a little bit of troponin. In the case of pulmonary embolism, troponins may be slightly elevated because of RV strain.

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13
Q

Managing Pulmonary Embolism

A

Need to put the patient on anti-coagulatory drugs; IV unfractionated heparin, LMWH or rivaroxaban.

Admit to hospital if complicated.

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