Chest pain

Question 1

When charting to rule out an MI, what is important to include in the chart

Answer 1

Pertinent negatives

Question 2

What is acute coronary syndrome

Answer 2

umbrella for conditions from stable angina to AMI

Question 3

What does it mean if nitroglycerin no longer has an effect on a person

Answer 3

1. they have unstable angina

2. their nitroglycerin has lost efficacy from exposure to light and/or air

Question 4

What are the main types of angina

Answer 4

Stable
Unstable
Prinzmetal/atypical

Question 5

What is stable angina

Answer 5

anginal symptomatology that occurs with the same degree of exertion and resolves with the same degree of rest and/ or same dosage strength and frequency of NTG

Question 6

What is unstable angina

Answer 6

angina that occurs with more frequent occurrence of anginal episodes, longer lived episodes or more easily provoked angina

Question 7

What is Prinzmetal (atypical) angina

Answer 7

Angina that occurs at rest

Question 8

Which characteristics are high risk for Acute Coronary Syndrome

Answer 8

Pressure or squeezing quality
Pain similar to prior AMI or angina
Radiation to neck, shoulders, or left arm
Associated dyspnea - esp diabetic or elderly

Question 9

What do you do for a patient with unstable angina

Answer 9

Send them to the ER! If they are in the office, put them on oxygen, give them nitroglycerin (if BP systolic isn’t lower than 100), and aspirin (chewable).

Question 10

Who is more likely to have atypical ACS symptoms

Answer 10

Women, drug users, diabetics, elderly

Question 11

What Physical exam findings are of note in acute coronary syndrome

Answer 11

may see low BP, diaphoresis, skin color, bradycardia, unstable pulse ox

Question 12

When is a family history of MI particularly significant

Answer 12

When it happened to first degree relative before the age of 60, with decreasing age making the history increasingly significant.

Question 13

What is the signature of an evolving or completed MI

Answer 13

ST elevation (called STEMI) wide and deep by a box

Question 14

What blood markers are used most commonly for AMI

Answer 14

creatine kinase-MB and troponin levels (most sensitive). troponin is normally run twice

Question 15

What are the leads you see an anterior wall MI in

Answer 15

V1-6 you will see an ST elevation

Question 16

When are EKG findings rendered useless

Answer 16

If someone has a bundle branch block, then all EKG findings are lost in that double peak it makes

Question 17

What does MONA stand for

Answer 17

M -morphine
O - oxygen
N - nitroglycerine
A - aspirin

Question 18

What are the leads you can see an Inferior wall MI

Answer 18

2,3, aVF

Question 19

What are the leads you can see a lateral wall MI

Answer 19

1 and aVL

Question 20

What is an aneurysm

Answer 20

a ballooning out, NOT a dissection

Question 21

What is the main risk of an aortic aneurysm

Answer 21

While the stretched vessel may occasionally cause discomfort, a greater concern is the risk of rupture which causes severe pain, internal hemorrhage and unless treated immediately, death

Question 22

What happens in Cardiac tamponade

Answer 22

rapid filling of the pericardial sack squeezes the heart which prevents it from expanding to fill with blood

Question 23

Who is at greater risk for cardiac tamponade

Answer 23

Often occurs as a result of chest trauma (both blunt and penetrating) but can also be caused by cancer, uremia, pericarditis or cardiac surgery

Question 24

What is Beck’s triad

Answer 24

classic findings of cardiac tamponade: low BP, acute JVD, muffled heart sounds

Question 25

What are the ssx of cardiac tamponade

Answer 25

Beck's triad, pulsus paradoxus, general signs and symptoms of shock such as tachycardia, breathlessness and decreasing level of consciousness

Question 26

what is pulsus paradoxus

Answer 26

drop of at least 10mmHg in arterial blood pressure on inspiration

Question 27

How does PE chest pain compare to MI

Answer 27

PE is much more localized and sharp

Question 28

What tests are run for a suspected PE

Answer 28

CXR, D-dimer, V/Q scan, pulmonary angiography, CT-PA

Question 29

What are ssx of a PE

Answer 29

tachycardia, hx of malignancy or DVT, pleuritic pain, dyspnea or tachypnea, or signs of deep venous thrombosis, hemoptysis

Question 30

what are ssx of pneumothorax

Answer 30

shortness of breath, fatigue, pain, no breath sounds and hyper-resonance over deflated lung, mb decreased pO2

Question 31

What is the classic patient to get a primary (spontaneous) pneumothorax

Answer 31

Tall, thin, smoking male 20-30 yo

Question 32

What are the ssx of pneumonia

Answer 32

Fever, cough, dyspnea. look for b-natrietic peptide to ddx from CFH

Question 33

What is the CXR protocol for pneumonia

Answer 33

repeat CXR 3-4 weeks after ssx have resolved to r/o malignancy

Question 34

What are characteristics that suggest GI source of chest pain

Answer 34

Pain persisting for more than one hour Pain that typically occurs post-prandially Lack of radiation of the pain Associated esophageal symptoms (heartburn, regurgitation, dysphagia) Pain relieved by antacid ingestion

Question 35

What are characteristics that suggest M/S source of chest pain

Answer 35

multiple areas of focal tenderness, pain is reproducible from palpation

Question 36

What is Tietze's syndrome

Answer 36

benign, painful, non-suppurative localized swelling of the costosternal, sternoclavicular, or costochondral joints, most often involving the area of the second and third ribs

Question 37

What are common M/S etiologies of chest pain

Answer 37

``` Shingles - even 2 weeks before an outbreak Fibromyalgia Rheumatoid arthritis Ankylosing spondylitis Psoriatic arthritis Fractures and subluxations of rib cage ```