January 13, 2016 - SG2 - Chest Discomfort II Flashcards Preview

COURSE 3 > January 13, 2016 - SG2 - Chest Discomfort II > Flashcards

Flashcards in January 13, 2016 - SG2 - Chest Discomfort II Deck (13):

DDx for Chest Discomfort

Falls into one of three broad categories...

1. Cardiac

2. Pulmonary

3. Other


DDx for Pulmonary Chest Discomfort

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


DDx for Cardiac Chest Discomfort

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*


DDx for "Other" Chest Pain

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


Acute Coronary Syndrome - Profile

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.


Pericarditis - Profile

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

Physical Exam - maybe a triphasic rub

Labs - none

ECG - diffuse ST elevation, PR depression


Aortic Dissection - Profile

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


Pulmonary Embolism - Profile

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


Pneumonia - Profile

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


Pneumothorax - Profile

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


Well's Score

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


Slightly Elevated Troponin T

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.


Managing Pulmonary Embolism

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

Admit to hospital if complicated.

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