Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

OSCE IV > Chest Pain Clinical Reasoning > Flashcards

Chest Pain Clinical Reasoning Flashcards

1
Q

What is the classic presentation of stable angina?

A

Substernal exertional chest discomfort

Sxs resolve promptly with rest or nitroglycerin and do not change over the course of weeks

Usually pt has CHD risk factors

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What is the cause of stable angina?

A

Mismatch between myocardial oxygen supply and demand.

Common first presentation of coronary heart disease (CHD) usually due to coronary artery stenosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are the important tests for workup of stable angina?

A

cardiac stress test, CT coronary angiogram, or angiogram

Laboratory testing: blood glucose and lipid panel to look for diseases which increase likelihood of ischemic process

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What are the risk factors for CHD? (important to ask for chest pain workup)

A

male sex

age >55 yo in men, >65 yo in women

tobacco use

diabetes mellitus

hypertension

abnormal lipid profile

other: other vascular diseases, CKD, elevated inflammatory markers, lifestyle factors (sedentary, obesity, etc), cocaine use

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

How might women describe angina differently than men?

A

More likely to use terms like “burning” or “tender”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What 3 questions should you ask to categorize a patient’s chest pain as either typical angina, atypical angina, nonanginal?

A
  1. Where is your pain? (substernal = pos)
  2. Does your pain come on or get worse when you walk, walk fast, or climb stairs? (exertional = pos)
  3. Does your pain get better with rest? (yes = pos)

If all 3 positive screen –> typical angina

If only 2 positive –> atypical angina

If only 1 positive –> nonanginal chest pain

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What do stress tests do?

A

attempt to induce and detect myocardial ischemia (can use exercise or drug induced if needed, ex. dobutamine)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Other than exertion, what are two triggers for stable angina?

A

Emotional stress, cold weather

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

How would you decide between a stress test or angiography for further workup for suspected stable angina?

A

Pt with high likelihood of disease may not benefit from stress test bc the test is not needed for diagnostic purposes or they may not be able to undergo revascularization

Angiography is the gold standard for diagnosing CHD. Indications are abnormal stress test indicating substantial ischemia, ischemia at a low workload on exercise test, diagnostic uncertainty.

Can move straight to angiography without stress test if sxs are disabling despite therapy or if they have heart failure

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

How can you treat stable angina?

A

Tx goal = relieve sxs, inhibit disease progression

  1. Lifestyle modification (smoking cessation, exercise, weight loss, low fat and low cholesterol diet)
  2. Medication to treat sxs:
    • Beta blocker (first line, decrease oxygen demand)
    • Nitrates (increase coronary blood flow, short acting used to relieve episodes)
  3. Medication to slow sx progression:
    • aspirin
    • high intensity statin
    • BP control if pt has HTN
    • ACE-I/ARB in patients at highest risk (ex. diabetes, heart failure)
    • gylcemic control
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What is the classic presentation for GERD?

A

heartburn (burning, substernal, chest discomfort), regurgitation, dysphagia, symptoms worse at night and after large meals, worse lying down

(note dysphagia raises possibility of obstructing lesion and mandates prompt eval, usually with upper endoscopy)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What factors typically make GERD symptoms worse? (aggravating factors)

A
  • ingesting large (esp fatty) meals
  • lying down after meal
  • using tobacco
  • eating foods that relax lower esophageal sphincter (chocolate, alcohol, coffee, peppermint)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

How can you diagnose GERD?

A

suggestive symptoms and response to therapy generally considered diagnostic

EGD can be done in pts with alarm symptoms (dysphagia, odynophagia, weight loss, GI bleeding, iron deficiency anemia) or signs suggestive of complicated disease (early satiety, vomiting, extra-esophageal symptoms, unclear etiology of chest pain, longstanding sxs - to check for Barrett esophagus, require long term therapy, respond poorly to appropriate therapy)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

what is the treatment for GERD?

A

8 week course of once per day proton pump inhibitor (PPI) = first line

H2 receptor blockers can be used for maintenance therapy (not initial tx)

motility agents may also be useful (not initial tx)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

what is the classic presentation for acute MI?

A

Middle aged man with risk factors for CHD with crushing substernal chest pressure, pain radiating to left arm, diaphoresis, nausea/vomiting, shortness of breath, feeling of impending doom

*Note: we do a bad job at recognizing (and historically studying) MI in women, younger and older patients. There are also frequent atypical presentations

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

When does an MI happen?

A

prolonged failure to perfuse an area of myocardium leading to cell necrosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

what is the most common etiology of an acute MI?

A

coronary plaque ruptures causing thrombosis and subsequent blockage of a coronary artery

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

what are the broad differences between STEMI and nSTEMI?

A

STEMI

  • transmural ischemia or infarction
  • typically caused by complete occlusion of coronary artery
  • initial diagnosis requires strict ECG criteria

nSTEMI

  • less severe, usually injuring only subendocardial tissue
  • typically caused by incomplete occlusion of a coronary artery
  • higher subsequent risk for STEMI than for pts with STEMI
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is the first initial step for workup if suspected MI?

Next step?

A

EKG within 10 minutes of arrival to ED!

Obtain peripheral blood sample to check CK-MB and troponin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What cardiac biomarkers are measured in suspected MI?

A

serum creatine kinase MB subunit (CK-MB)

troponin

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

how can kidney disease affect troponin levels?

A

may be elevated (increased risk false positives)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

How can MI present in women specifically?

A
  • more likely to present without chest pain
  • often report prodromal sxs (fatigue, dyspnea, insomnia)
  • dyspnea, weakness, fatigue common sxs
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

what would the expected findings be for STEMI on EKG?

A

ST-segment elevation/depression, T-wave inversions, Q waves

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is the classic presentation for unstable angina (UA) or nSTEMI?

A

new or worsening sxs of CHD, only differentiated by absence (UA) or presence (nSTEMI) of myocardial enzyme elevation in peripheral blood samples

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

what distinguishes unstable angina from stable angina?

A

UA is angina that is new, worsening in severity or frequency, or occurs at rest

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

what is the pathophysiology of UA or nSTEMI?

A

primarily caused by acute plaque rupture followed by platelet aggregation

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

what are the 3 presentations of UA?

A
  1. angina at rest
  2. new onset (<2 months) angina
  3. increasing or accelerating angina
28
Q

what are some features/findings that increase likelihood that a patient’s sxs represent an ACS (ie unstable angina or nSTEMI)?

A

chest pain or L arm pain that reproduces prior angina

hx of CHD

transient mitral regurgitation murmur

hypotension

diaphoresis

pulmonary edema

crackles

29
Q

what are the classic EKG findings of UA/nSTEMI?

A

nonspecific changes, including T-wave inversions, ST-segment depressions

30
Q

what is the acute treatment for UA/nSTEMI?

A

oxygen, aspirin, enoxaparin, clopidogrel, beta blocker, nitrates

urgent coronary angiography if unstable patient

31
Q

what is the classic presentation of aortic dissection?

A

older man with hx of hypertension and possibly atherosclerotic disease who complains of “tearing” chest or back pain

Pain may be associated with vascular complications (syncope, stroke, cardiac ischemia, HF secondary to acute aortic regurgitation(

Physical exam: asymmetry in upper extremity BPs and the chest radiograph shows widened mediastinum

32
Q

what is the pathophys (brief) of an aortic dissection?

A

dissection begins with a tear in the aortic intima allowing blood to dissect between the intima and media

33
Q

what are 7 risk factors for aortic dissection?

A
  1. hypertension
  2. atherosclerosis
  3. known aortic aneurysm
  4. prior aortic dissection
  5. diabetes
  6. Marfan syndrome
  7. cocaine use (esp in younger patients(
34
Q

what are symptoms of an aortic aneurysm (that has not dissected)?

A

can detect on chest XR

can also present with aortic regurgitation, pain, or impingement on other structures like trachea, esophagus, or recurrent laryngeal nerve

35
Q

what are the 3 most important findings that would point to aortic dissection in a patient with chest pain?

A
  1. acute or tearing or ripping pain
  2. aortic or mediastinal widening (on chest XR)
  3. asymmetric pulse or BPs
36
Q

what is the gold standard for diagnosis of aortic dissection?

what do most patients undergo for diagnostic testing?

A

angiography is gold standard

most patients undergo noninvasive tests (CT or TEE (transesophageal echocardiography))

37
Q

what is the classic presentation of pleural effusion?

A

small –> usually asymptomatic

large –> dyspnea with or without pleuritic chest pain

often cough, shortness of breath, fever

presentation also depends on etiology. If parapneumonic, may also have signs/sxs of pneumonia. If neoplasm, HF, PE, or rheumatologic disease, may have sxs specific to those diseases

38
Q

what is the differential for an exudative pleural effusion?

A

increased capillary permeability or disruption of pulmonary lymphatics

parapneumonic effusion, malignancy, pulmonary embolism (75%), viral infection, post CABG, subdiaphragmatic infections and inflammatory states, chylothorax/uremia/connective tissue diseases

39
Q

what is the differential for transudative pleural effusions?

A

caused by increased hydrostatic pressure, decreased oncotic pressure, or increased negative intrapleural pressure

heart failure, cirrhosis with ascites, pulmonary embolism (25%), nephrotic syndrome, severe hypoalbuminemia

40
Q

what physical exam findings are consistent with a diagnosis of pleural effusion?

A

dullness to chest percussion, area of egophony just superior to effusion

confirmation on chest XR, ultrasound, or other imaging

41
Q

how can the Light criteria be used to determine etiology of pleural effusion?

A

effusion is exudative if any of the following are present:

  1. pleural fluid protein/serum protein > 0.5
  2. pleural fluid lactate dehydrogenase (LD)/serum LD > 0.6
  3. pleural fluid LD > 2/3 upper limit normal for serum LD
42
Q

what should pleural fluid testing always include for workup of pleural effusion?

A

LD, protein, albumin, pH, cell count

43
Q

what characterstics of a pleural effusion would warrant thoracentesis?

A

clinically significant effusion >1cm on chest film (unless suspected etiology of HF)

44
Q

what is the classic presentation for patient with acute pericarditis?

A

young adult, 1 week of viral sxs and chest pain, pleuritic chest pain, pain radiates to trapezius ridge, improves with leaning forward, worse when lay down

Physical exam reveals friction rub, ECG reveals ST elevations and PR depressions in all leads

45
Q

what are some causes of pericarditis?

A

viral

TB and HIV

post MI and post cardiac surgery

SLE, RA

medication induced: procainamide, hydralazine

malignancy that has metastasized to pericardium

chest irradiation

uremia

*however most are considered ~idiopathic~ or due to undiagnosed virus

46
Q

how is pericarditis diagnosed?

A

characteristic pericardial friction rub

or

pt with chest pain and characteristic EKG findings (widespread ST elevations and PR depressions)

Once diagnosed, need to do echo to evaluate and exclude tamponade

47
Q

are cardiac enzymes helpful in diagnosing pericarditis?

A

no! often positive and therefore not helpful in distinguishing chest pain of pericarditis from cardiac ischemia

48
Q

what workup is indicated for pericarditis?

A

chest radiograph

BUN and Cr

TB test

antinuclear antibodies

blood cultures

49
Q

what is the treatment for uncomplicated pericarditis?

A

NSAIDs for pain relief

tx is supportive

50
Q

what are the characteristic clinical features of cardiac tamponade?

A

Tachypnea, dyspnea

Tachycardia

Pulsus paradoxus

Cardiogenic shock

Beck triad: hypotension, elevated JVD, muffled heart sounds

51
Q

what are the characteristic clinical features of heart failure exacerbation?

A

Chest pressure

Cough, dyspnea

Hypoxemia

Crackles, JVD, peripheral edema

52
Q

what are the characteristic clinical features of esophageal perforation?

A

Retrosternal chest pain, neck pain, epigastric pain with radiation to the back

Dyspnea, tachypnea, tachycardia

Dysphagia

Signs of sepsis

Mackler triad (chest pain, vomiting, subcutaneous emphysema)

Mediastinal crepitus

History of recent endoscopy or severe emesis (Boerhaave syndrome)

53
Q

what are the classic clinical features of tension pneumothorax?

A

Severe, sharp chest pain

Dyspnea, hypoxemia

History of trauma

Hyperresonance, decreased breath sounds, tracheal deviation

Tachycardia, hypotension

54
Q

what are the characteristic clinical characteristics of peptic ulcer disease?

A

Epigastric pain (may present as chest pain)

Duodenal ulcer: pain relieved with food; weight gain

Gastric ulcer: pain exacerbated by food; weight loss

Signs of GI bleed

History of NSAID intake

55
Q

what are the characteristic clinical findings of pancreatitis?

A

Severe epigastric pain that radiates to the back (ie may present as chest pain)

Nausea, vomiting

Epigastric tenderness, guarding, rigidity

Upper abdominal pain

Hypoactive bowel sounds

History of gallstones or alcohol use

56
Q

what are the classic clinical features of Mallory-Weis syndrome?

A

Epigastric pain that radiates to the back (ie may present as chest pain)

Repeated episodes of severe vomiting

Hematemesis

Melena, dizziness, syncope

57
Q

what are the classic clinical features of pulmonary embolism?

A

Pleuritic chest pain

Acute onset dyspnea, hypoxemia

Cough, hemoptysis

Unilateral leg swelling or history of DVT

Hypotension, shock (if massive PE)

(although common presentation is asymptomatic)

58
Q

what initial diagnostic testing can be used to diagnose pulmonary embolism?

A

D-dimer levels

59
Q

what are the characteristic clinical features of costrochondritis?

A

Sharp, well-localized pain that is reproducible on palpation of costal cartilage

History of recent exercise/exertion/chest wall trauma

(clinical diagnosis, tx = pain management with acetominophen or NSAIDs, heat/ice packs, reduce activity that aggravates)

60
Q

what are the characteristic clinical features of acute herpes zoster?

What is tx?

A

Severe burning or throbbing pain (can present as chest pain)

Thoracic dermatomes most commonly affected

Maculopapular rash that develops into a vesicular rash in a dermatomal distribution

Immunocompromised status

Tx = antivirals

61
Q

what are the characteristic clinical features of panic disorder?

What are tx options?

A

Chest tightness, palpitations, tachycardia

Tachypnea

Diaphoresis, dizziness

Paresthesias

Anxious appearance

Recent stressful exposure

Tx: breathing exercises, can give benzodiazepines acutely

62
Q

Describe the approach to a patient with a potentially life threatening cause of chest pain

A
63
Q

List 6 risk factors for DVT/PE

A
  1. recent travel/prolonged immobilization
  2. smoking
  3. oral contraceptives
  4. malignancy
  5. recent surgery
  6. personal or family hx of clotting disorder
64
Q

what are some important questions to ask for review of systems for chest pain?

A

nausea/vomiting, shortness of breath, hemoptysis, fever, sweating, syncope, bad taste in mouth, breathing faster than usual, palpitations, orthopnea, paroxysmal nocturnal dyspnea, LE edema

65
Q

Describe the approach to chest pain in the ER in a patient NOT in severe respiratory distress or shock

A

from Dr. Mutharsan’s clinical correlation lecture

66
Q

what are the classic features of chest pain with an MSK etiology?

A

very brief sharp, stabbing pain

localized (<3cm) dull ache

superficial chest wall location, worse with palpation

positional or pleuritic pain

worse with neck/arm motion

OSCE IV (4 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions