Eval of CP

Question 1

CP Differentials (5)

Answer 1

CP Is Overly Tough!
CV
Pulm
Infectious
Trauma
OTHER

Question 2

CP Differential: CV

Answer 2

“AAAs”
ACS
AAA!!!!
AS

Question 3

CP Differential: Pulm

Answer 3

PE

Question 4

CP Differential: Infectious

Answer 4

“Please pardon my infection”
PNA
Pleurisy
Myocarditis

Question 5

CP Differential: Trauma

Answer 5

“Bear Coughs cause Problems”
PTX
Chest Wall Fx/contusion
Boerhaaves syndrome
Costochondritis

Question 6

CP Differential: Other

Answer 6

“GG & PEG Took Pills”
GI- GERD, PUD, Esophageal
GB
Psych
Toxicity

Question 7

Triad of SAD

Answer 7

Syncope
Angina
Dyspnea

Question 8

What % of CP have unstable Heart Dz?

Answer 8

1.5%

Question 9

What is the MCC Dx of CP IN THE PCP OFFICE?

Answer 9

CWS: Chest Wall Syndrome

Question 10

T/F: It is acceptable to document Nonspecific CP or Atypical CP

Answer 10

False! Atypical is typical of something!
Use Noncardiac CP of CWS

Question 11

What is the MCC of CP?

Answer 11

MSK pain

Question 12

Why do we not see the 13% of CP with ACS in the output clinic?

Answer 12

They usually go to the ER

Question 13

True goals of CP w/u? (4)

Answer 13

*Who is stable v unstable
* Who is low risk
*Who needs further testing (high risk of unstable heart dz in next 90d)
*Who needs prompt transfer

Question 14

Where to start in CP workup?

Answer 14

ABC’s

Question 15

When to initially call 911

Answer 15

If pt is in resp distress or abnl VS
(Be lenient w/mild HTN or slight tachy)

Question 16

What should you do immediately after ABC’s?

Answer 16

EKG

Question 17

2 important HPI Q’s to ask w/CP

Answer 17

**“Have you had pain like this before?”
were you evaluated for it?
***“Have you ever had a heart exam/work up before?” stress testing in last 90d- low proability of event

Question 18

7 Other important HPI Q’s

Answer 18

*“Are you currently having chest pain?”
*“What were you doing when this started?” or
*“What seems to bring the pain on?”
*“How long did it last, what made it go away?”
*“Is it worse with activity?”
*“Do you have a family h/o heart problems?”
*“Have you taken an aspirin today?”
baby or full? ACS- full dose

Question 19

Worse w/Postprandial?

Answer 19

GI

Question 20

Worse w/Exertion?

Answer 20

Cardiac

Question 21

Worse w/cold, emotion, stress, sex?

Answer 21

Cardiac

Question 22

Worse w/Swallowing?

Answer 22

Esophageal

Question 23

Worse w/Body position, movement, deep breathing?

Answer 23

MSK

Question 24

Relief w/Antacids or food?

Answer 24

Gastro-esophageal

Question 25

Relief w/Sublingual nitro

Answer 25

Esophageal or cardiac

Question 26

Is response to nitro diagnostic?

Answer 26

HELL NO

Question 27

Relief w/GI cocktail

Answer 27

GI or Cardiac

Question 28

Is response to GI cocktail (viscous lido & antacid) diagnostic?

Answer 28

Hell NO!

Question 29

Relief w/rest

Answer 29

Cardiac

Question 30

Relief w/sitting up & leaning forward?

Answer 30

Pericarditis

Question 31

Assoc sx: Belching, bad taste in mouth, dysphagia

Answer 31

Esophageal dz

Question 32

Assoc Sx: Emesis

Answer 32

MI or GI

Question 33

Is diaphoresis a good indicator of MI?

Answer 33

YES! if they are diaphoretic, you should be diaphoretic. **We cannot make ourselves sweat.

Question 34

Is syncope a good indicator of badness? Which one most of all?

Answer 34

YES- DISSECTION PE, ruptured AAA, AS

Question 35

Is near syncope a good indicator of MI?

Answer 35

yeah

Question 36

What age group is fatigue an indicator of MI?

Answer 36

Presenting complaint in elderly

Question 37

Region of CP: which 2 are most indicating of MI?

Answer 37

Radiation to arm (1 or both) Large areas of discomfort

Question 38

Which pain region is indicative of aortic dissection?

Answer 38

B/W scapulae

Question 39

T/F: severity is a useful predictor of CAD

Answer 39

nope. can have 6/10 with MI and 10/10 with anxiety.

Question 40

What 2 timings are indicative of ischemia?

Answer 40

*Gradual w/↑ onset over time *Circadian rhythm (worse in the morning) correlating w/ ↑ SNS tone.

Question 41

Timing: crescendo pattern is indicative of?

Answer 41

Esophageal dz

Question 42

Timing: Abrupt onset w/greatest intensity in the beginning? (3)

Answer 42

PTX Dissection Acute PE

Question 43

If it lasts for seconds or constant over weeks, is it ischemic?

Answer 43

NO

Question 44

2 important parts of the PMHx

Answer 44

Prior CV hx FHx

Question 45

Important risk factors

Answer 45

tobacco use FHx DM HTN, Lipids Cocaine use

Question 46

Important risk factor for PE

Answer 46

DVTs

Question 47

Important risk factor for Aortic Dissection (2)

Answer 47

Marfans Pregnancy

Question 48

Important risk factor for PUD (2)

Answer 48

ETOH NSAIDS

Question 49

3 ACS exam findings

Answer 49

*S3 or S4 (S4 never normal) *SBP <80mmHg (would rather have a htn pt-perfusion) *Crackles on auscultation

Question 50

Likelihood ratio: LR >1 LR<1

Answer 50

Likelihood of correlation LR>1 result assoc w/dz LR<1 result assoc w/absence of dz

Question 51

>? LR is highly significant (Jaynstein says __)

Answer 51

10, 5

Question 52

7 Clinical features that inc. likelihood of MI

Answer 52

*Pain radiation to arms/shoulder *S4 *Hypotension *Prior MI *Crackles *Diaphoresis *NV

Question 53

Features that decrease likelihood of MI

Answer 53

Pleuritic pn "Sharp" "stabbing" Positional Reproducible

Question 54

High likelihood of ACS (5)

Answer 54

CP raditating to arms CP assoc w/exertion, CP assoc w/ nv CP assoc w/diaphoresis CP described as "worse than previous angina" or "like my last MI"

Question 55

Low likelihood of ACS (4)

Answer 55

Stabbing, positional, pleuritic CP Inframammary CP Not assoc w/exertion Reproducible w/palpation

Question 56

Marburg Heart Score (5)

Answer 56

F>64, M>54 Known CAD, CVD, PVD Pain worse w/exercise Pain not reproducible w/palpation Pt assumes pn is cardiac

Question 57

If ECG is nondiagnostic but CP is susp. for CAD....

Answer 57

→further testing with cardiac biomarkers (troponin) is rec. to eval NSTEMI →to ER

Question 58

Consider CXR if there is evidence of ___ dz (3)

Answer 58

Pulm =cough, dyspnea, or a hx of pulmonary disease

Question 59

Is there a guideline for Outpt troponins?

Answer 59

Nope

Question 60

How to check for BBB?

Answer 60

V1, V6 (R-R')

Question 61

What is the standard of care in ED for troponin use (from sx onset)? <3hrs >3hrs

Answer 61

<3hrs. baseline trop & repeat in 1hr >3hrs baseline trop only

Question 62

What is the default position for pts who have sx suggestive of ACS?

Answer 62

Undergo transfer for emergent eval w/o prior trop testing (DONT WASTE TIME)

Question 63

"It is reasonable to use a single troponin test in general practice to exclude the possibility of acute myocardial infarction (AMI) in ..."

Answer 63

asx pts whose sx resolved at least 12hr prior, so long as they have no high-risk features and a nl ekg

Question 64

EKG AMI criteria:

Answer 64

ST ↑ >2mm in 2 cont leads

Question 65

EKG Ischemia criteria:

Answer 65

Large, >2mm Q waves in inferior leads ST ↓ in cont leads, T wave inversion in cont leads

Question 66

Lateral Leads

Answer 66

V5, V6, I, AVL CircumfLex

Question 67

Septal Leads

Answer 67

V1, V2 LAD

Question 68

Anterior Leads

Answer 68

V3, V4 LAD

Question 69

Inferior Leads

Answer 69

II, III, AVF RCA

Question 70

AV block is a PR interval...

Answer 70

>1 large box

Question 71

Axis leads?

Answer 71

V1, AVF

Question 72

Will a PPI alter cardiac testing?

Answer 72

Nope

Question 73

What medication should be given for primary prevention of ACS

Answer 73

81mg ASA

Question 74

2 Indications to check a CBC in CP

Answer 74

if infectious or GI bleed

Question 75

ER HEART score Low risk?

Answer 75

H- Hx of same E-EKG A-Age R-Risk factors T-Trop 0-3 is low risk

Question 76

Can post prandial pain be ischemic?

Answer 76

yes

Question 77

Value of careful __ & ___ to CYA w/CP

Answer 77

H&P!!