Non-Cardiac Chest Pain Flashcards
(81 cards)
<p>What is GERD </p>
<p>Condition in which the stomach contents (acid) moves backward from stomach to esophagus</p>
<p>What is the etiology of GERD?</p>
<p>1) Transient relaxation of Lower Esphageal Sphincter
2) Low basal LES tone
3) Acid Hypersecretion (Zollinger-Ellison syndrome) </p>
<p>Clinical features of GERD</p>
<p>1) Acid regurgitation and Pyrosis (Heart Burn)
| 2) May have sour taste, Waterbrash, Lump in throat sensation, Belching</p>
<p>How is GERD Investigated?</p>
<p>1) Clinical diagnosis most often based on symptoms and if there is relief from a trial of pharmacotherapy
2) Gastroscopy can identify complications such as esophageal ulcers, and Barretts esophagus
3) 24 hour ambulatory pH</p>
<p>Treatments for GERD?</p>
<p>1) Lifestyle: Elevate head of bed, avoid fatty/spicy foods,EtOH, Acid foods (coffee, tomatoes, citrus, quit smoking
2) PRN antiacids
3) H2 receptor antagonists and PPI </p>
<p>What are the 2 types of esophageal spasm?</p>
<p>1) Diffuse esophageal spasm
- Normal amplitude of contractions but uncoordinated
2) Hypertensive peristalsis
- coordinated contractions but of increased amplitude </p>
<p>How to diagnose Esophageal spasm?</p>
<p>1) Barium Swallow: can show contractions
| 2) Esophageal Manometry: measures pressure of esophageal contractions</p>
<p>4 Management strategies for esophageal spasms?</p>
<p>1) Phosphodiesterase inhibitor (Viagra) - relaxes smooth muscle
2) Botulinum toxin
3) Diet - puree foods, avoid triggers
4) Surgical (myotomy with findoplication) </p>
<p>Name 6 types of esophagitis</p>
<p>1) Reflux
2) Infectious
3) Pill
4) Eosinophilic
5) Radiation
6) Chemoradiation</p>
<p>Which investigations aid in the DX of esophagitis?</p>
<p>1)CBC in pts with neutropenia or immunosuppression
2) CD4 count, HIV testing if risk factors present
3) Collagen work-up based on underlying disease
4) Imaging
- Double contrast barium study
- Upper endoscopy
</p>
<p>TX of esophagitis</p>
<p>1) Hemodynamic stabilization and pain management
2) Depends of causal etiology
3) Surgury (fundoplication) may be needed
4) Medication
- PPI for GERD or ABX for infections </p>
<p>What is Fundoplication?</p>
<p>Surgery to prevent stomach contents from returning to the esophagus. Achieved by wrapping the upper portion of the stomace (fundus) around the lower portion of the esophagus </p>
<p>What is Boerhaave's Syndrome?</p>
<p>Spontaneous Rupture of the Esophagus </p>
<p>What causes Boerhaave's Syndrome?</p>
<p>- Sudden rise in intraluminal pressure
- Ex. Pressure produced during vomitting
- Commonly associated with overindulgence of food or alcohol </p>
<p>How does Boerhaave's Syndrome typically present?</p>
<p>- Repeated episodes of retching and vomiting
- Most common in middle aged men
- Recent dietary or EtOH intake
- No blood in emesis
- SOB
- Mackler Triad
- Pneumomediastinum </p>
<p>What is Mackler Triad and which condition is it associated with?</p>
<p>1) Vomiting
2) Lower Thoracic Pain
3) Subcutaneous Emphysema
* Associated with Boerhaave's Syndrome</p>
<p>Which investigation can help the DX of Boerhave's syndrome?</p>
<p>1) CBC - 50% of pts with this condition have a hematocrit value of about 50%, due to loss of fluid into pleural space
2) Thorocentesis: many pts present with plueral effusion. Undigested food particles and gastric juices often found in this fluid. pH under 6, elevated amylase and squamous cells from saliva may be seen</p>
<p>TX of Boerhaave's syndrome?</p>
<p>1) IV fluid resuscitation
2) Broad Spectrum ABX (Carbapenems)
3) NG tube and surgical consult (keep pt NPO)
</p>
<p>What is a Mallory-Weiss Tear?</p>
<p>Upper GI bleeding secondary to a longitudinal tear at the gastroesophageal junction</p>
<p>Risk factors for Mallory-Weiss Tear?</p>
<p>- Retching, Vomiting, Straining, Hiccups, Cough, Primal Scream Therapy, Blunt Abdominal trauma, CPR
- Hiatal Hernia </p>
<p>How does a Mallory-Weiss Tear present?</p>
<p>- 85% with Hematemesis
| - Other S/S relating to blood loss: Tachy, hypotension, orthostatic changes, shock </p>
<p>Ix for Mallory-Weiss Tear?</p>
<p>- Endoscopy, both for diagnosis and therapy
| </p>
<p>Tx of Mallory-Weiss Tear?</p>
<p>- Electrocautery
- Sclerosant injection (EtOH, Polidocanol)
- Argon Plasma coagulation
- Band ligation
- Hemoclip
- Balloon tamponade </p>
<p>What is costochondritis?</p>
<p>Inflammation of the costochondral or costosternal joints causing pain or tenderness</p>
Presentation of costochondritis?
- Chest wall pain - Often occurs at more than 1 sire - Hx of repeated minor trauma - Made worse with trunk movement, deep inspiration and or exersion - Sharp nagging pain - Severe but waxes and wanes
Management of costochondritis?
NSAIDS
What is herpes zoster?
Shingles, reactivation of Varicella zoster virus | - Reactivation occurs secondary to some other source of immunosuppression
Complications of herpes zoster?
- CNS involvement (muscle weakness, CN palsies, diaphragmatic paralysis, neurogenic bladder, colonic pseudo-obstruction) - Herpes zoster ophtalmicus - Herpes zoster oticus
Clinical presentation of Herpes Zoster?
- Unilateral dermatomal eruption, occuring 3-5 days after onset of pain - Paresthesia of effected dermatome - vesicles, bullar, and pustules on erythmatous, edematous base - 50% thoracic, 10-20% trigeminal, 10-20% cervical
What does a Tzanck Smear confirm?
Can confirm that a lesion is herpetic (Herpes Zoster)
Mangement of Herpes Zoster?
- Antiviral (ex. Famciclovir) for 7 days (must be started within 72hr to be of benefit) - Analgesia (Narcotic, TCA, Anticonvulsant) - TCA's shown to be most benefit with post herpetic neuralgia
What is a Pleural Effusion/Empyema
- Excess amount of fluid in the pleural space (normal is 25ml or under) - Effusion - fluid - Empyema - pus
What is the difference between a transudative and exudative fluid?
- Transudative: Due to alteration of systemic factors that affect the formation and absorption of pleural fluid. (^ capillary hydrostatic pressure, v plasma oncotic pressure) - Exudative: Increased permability of pleural capillaries or lymphatic dysfunction. - From inflammatory conditions
What can cause transudative effusion?
CHF, Nephrotic syndrome, Peritoneal dialysis, cirrhosis, Cystic fibrosis
What can cause exudative effusion?
PE (most often exudate), Pneumonia, TB, Malignancy
Signs & Symptoms of Pleural Effusion?
- Often asymptomatic - Progressive dyspnea - Cough - Pleuritic chest pain - Fever (empyema)
Which investigations are useful in DX Pleural Effusion?
- CXR - Thoracentesis (analyze fluid) - Pleural biopsy - U/S - CT scan
How is pleural effusion/empyema managed?
- Treat underlying disease - Therapeutic thoracentesis - Tube thoracostomy
What is a pneumothorax?
The presence of air or gas in the pleural cavity
What are 5 different types of pneumothorax?
1) Spontaneous 2) Tension 3) Pneumomediastinum 4) Iatrogenic 5) Traumatic
What type of person is at highest risk of having a spontaneous pneumo?
Primary: Tall, healthy young males | Secondary: Those with underlying lung disease (Pneumonia, lung abscess, Cancer, emphysema)
What can cause an iatrogenic pneumo?
In hospital, Central venous catheters, thoracentesis, mechanical ventilation
What is a tension pneumothorax?
Occurs when injured tissue forms a one way valve. This lets air into pleural space on inspiration but does not allow it to leave on expiration
How do you confirm a diagnosis of pneumothorax?
CXR
How do you manage a primary spontaneous pneumo?
- under 15%, no Sx = O2 and watch - under 15%, Sx present = needle aspiration - over 15% = pigtail catheter with low suction
How do you manage a secondary spontaneous pneumo
tube thoracostomy
What is a pulmonary abscess?
Necrosis of the pulmonary tissue and formation of cavities containing necrotic debris or fluid - Caused by microbial infection
Are the most common causative organisms of pulmonary abscesses aerobic or anaerobic?
Anaerobic from the gingiva | - Gingivitis and peridontal disease common in people with pulmonary abscess
How does a pulmonary abscess typically present?
- Over a period of weeks-months - Fever - Productive cough - Night sweats - Anorexia - Weight loss - Hemoptysis - Pleuritis
What may you find on exam if the person has a pulmonary abscess?
- v Breath sounds - Dullness on percussion - Coarse inspiratory crackles - Friction rubs - Digital clubbing
What investigations could be done to DX pulmonary abscess?
- CBC w diff (Leukocytosis, left shift) - C&S and O&P sputum - CXR
What is a pulmonary embolism?
Obstruction of the pulmonary artery or one of its branches by and object that originated elsewhere in the body (Thrombus, tumour, air, fat)
What are 3 risk factors for PE?
1) Stasis 2) Endothelial Cell Damage - Post surgery - Trauma - Inflammation 3) Hypercoagulable State - Malignancy - CA treatment - Exogenous estrogen - Pregnancy and post partum - Past DVT, PE - Family Hx - Nephrotic syndrome - Age - Coagulopathies
What is Virchow's triad? Which condition is it associated with?
1) Venous stasis 2) Endothelial injury 3) Hypercoagulable state * Associated with increased PE risk
Where do most emboli that cause PE arise from?
Lower extremity proximal veins (Iliac, femoral, popliteal)
What 3 pathological things happen during PE?
1) Pulmonary infarction 2) V/Q mismatch (dead space, ventilation intact but no perfusion) 3) Cardiovascular Compromise - increase in vascular resistance due to obstruction and hypoxic vasoconstriction - reduced left ventricular filling due to backflow in right, leads to lower cardiac output
Symptoms of PE
- Dyspnea - Pleuritic chest pain - Cough - DVT - Orthopnea - Wheezing - Hemoptysis - Tachypnea - Tachycardia - JVD - Decreased breath sounds
What lab test may support DX of PE?
- D-dimer (sensitive but poorly specific) | - ABG (hypoxemia, resp. alkalosis)
