Chest & Abd Pain

Question 1

Thoracic chest pain DDX

Answer 1

Cardiac: CAD (angina, MI), Pericarditis, Pulmonary HTN, PE, Aortic dissection, mitral valve prolapse, Myocarditis

Non-Cardiac: MSK, GERD, Esophageal disorder, Lung disease, Pleural disease, gall bladder disease, anxiety

Question 2

How is pleuritic pain described?

Answer 2

Pain is increased by deep breathing, coughing, etc…

Question 3

Pleuritic chest pain DDX

Answer 3

PE, Pneumothorax, Pneumonia, Pleurisy

Question 4

Possible causes of chest wall (somatic) pain

Answer 4

Intercostal Strain, Costochondritis, Herpes Zoster

Question 5

sudden, very intense tearing pain =

Answer 5

aortic dissection

Question 6

Becks triad

Answer 6

for cardiac tamponade = hypotension, JVD, muffled heart sounds

Question 7

Essential workup for chest pain

Answer 7

EKG
CXR
Troponin (does not r/o AMI if taken w/i 12 hrs)

Question 8

Acute coronary syndrome and acute MI treatment

Answer 8

MONA (BB if tachycardic or hypertensive)

Goal is reperfusion (fibrinolysis less than 12 hrs)

Question 9

Cardiac tamponade treatment

Answer 9

Pericardiocentesis (just below xyphoid aiming for left shoulder at 45 degrees)

Question 10

Pulmonary embolism treatment

Answer 10

Stable: LMWH (Enoxaparin 1mg/kg subQ)
Unstable: Thrombolysis (Alteplase 100mg over 2hrs)

Question 11

Aortic dissection treatment

Answer 11

Initial: Central Line, Morphine for pain, fluids for hypotension
Stable: Propranolol, Diltiazem, Enalapril (heart, vessels, BP)
Unstable: Surgery

Question 12

Esophageal Spasm/Rupture treatment

Answer 12

Spasm: GI cocktail, nitro
Rupture: Airway, Fluids, Surgery

Question 13

Pericarditis treatment

Answer 13

NSAIDs, Colchicine (70-90% self limited)

Question 14

Pneumothorax (Tension) treatment

Answer 14

Severe/Unstable: needle decompression (14-guage 2nd intercostal MCL)
Definitive Tx: chest tube thoracotomy (36-French 4th intercostal AAL)

Question 15

dyspnea vs respiratory distress

Answer 15

dyspnea is subjective

respiratory distress is objective (hypoxia, tachypnea, cyanosis, etc.)

Question 16

Red flags of dyspnea

Answer 16

• decreased mental status (anxiety-lethargy)
• labored breathing (tachypnea/accessory muscle use)
• speaking in fragmented sentences
• Cyanosis

Question 17

Life threatening dyspnea

Answer 17

Upper airway obstruction (FB, angioedema, hemorrhage)
Tension pneumothorax
PE

Question 18

Essential workup for dyspnea?

Answer 18

chest XR!!!

pulse ox, ABG, EKG

Question 19

s/s: moist crackles, JVD, pedal edema, S3 heart sound, pink/frothy sputum

Answer 19

CHF exacerbation or pulmonary edema

Question 20

triggers: pulm infection, allergens

s/s: wheezing, poor air movement, coughing

Answer 20

asthma or COPD exacerbation

Question 21

Triggers: foreign body, infection (epiglottitis), hypersensitive reaction (angioedema)
s/s: stridor, drooling, hoarseness, swelling

Answer 21

upper airway obstruction

Question 22

Triggers: viral URI, influenza, hx of respiratory problems

s/s: cough, fever, pleuritic chest pain

Answer 22

pneumonia

Question 23

Triggers: hx of PE/DVT, smoking, OCP use, cancer, immobilization, recent trauma
s/s: dyspnea, tachypnea, tachycardia, hemoptysis

Answer 23

pulmonary embolism

Question 24

Triggers: young, tall, male, smoker

s/s: pleuritic chest pain, uneven chest rise/breath sounds, tracheal shift

Answer 24

pneumothorax

Question 25

Goals for oxygen level in dyspnea patient

Answer 25

greater than 90%

Question 26

Initial treatment for all dyspnea patients

Answer 26

facemask with 100% oxygen caution if COPD

Question 27

Labs for dyspnea workup

Answer 27

CBC, BMP, BNP, D-dimer, sputum/blood culture, tox screen

Question 28

How is a pneumothorax managed?

Answer 28

Observe if less than 15% Tube thoracotomy if over 15-20% or enlarging on repeat CXR

Question 29

________ refers to a sudden, severe abdominal pain of unclear etiology that is less than 24 hrs in duration.

Answer 29

acute abdomen

Question 30

What type of abdominal pain tends to make patients want to move around? type to make lie still?

Answer 30

visceral - move | parietal - lie still

Question 31

Describe ischemic visceral abdominal pain

Answer 31

severe, diffuse, and disproportionate to exam

Question 32

Which organ visceral pain is referred to umbilicus?

Answer 32

midgut

Question 33

Which organ visceral pain is referred to superior of umbilicus?

Answer 33

foregut (liver, stomach)

Question 34

How to test Murphy's sign? Seen with what?

Answer 34

Pain with inspiration when pressure applied under right costal margin gall bladder inflammation

Question 35

McBurney's Point pain indicates _________.

Answer 35

appendicitis

Question 36

positive psoas sign indicates _________.

Answer 36

retrocecal appendicitis

Question 37

________ sign indicates pelvic inflammation.

Answer 37

obturator

Question 38

When to do a rectal exam with abdominal pain?

Answer 38

possible GI bleed, prostatitis, hemorrhoids or fissures

Question 39

Why order lipase for abdominal pain?

Answer 39

evaluate pancreas

Question 40

What patients with abdominal pain need urgent surgery?

Answer 40

acute, severe pain pulsatile mass shock sx's

Question 41

Common IV antiemetics

Answer 41

Zofran | Reglan

Question 42

Common IV antibiotics for abdominal pain

Answer 42

Ancef | Zosyn

Question 43

How to image renal stones?

Answer 43

CT without contrast

Question 44

Signs of small bowel obstruction on XR

Answer 44

air-fluid levels and dilation

Question 45

Signs of foreign bodies on XR

Answer 45

opacities

Question 46

Signs of perforation on abdominal XR

Answer 46

free air under diaphragm

Question 47

Admission criteria for abdominal pain

Answer 47

``` surgical intervention needed IV abx needed peritoneal signs unable to keep down fluids lack of pain control ```

Question 48

Discharge criteria

Answer 48

No surgical or severe condition found Able to keep down fluids Good pain control Able to follow discharge plan

Question 49

Admission criteria for dyspnea

Answer 49

Requires assisted ventilation Ongoing hypoxia Requires ongoing treatment

Question 50

colicky abdominal pain and spasm of smooth muscle comes from pathology where?

Answer 50

intestines, gall bladder