Noncardiac chest pain

Question 1

Name immediate life-threatening causes of chest pain (6)

Answer 1

• MI
• Aortic dissection
• EP
• Tension pneumothorax
• Esophageal perforation
• Pericardial effusion with tamponade

Question 2

Define : BOERHAAVE SYNDROME (2)

Answer 2

• Barotrauma-induced rupture of the esophagus,
• usually caused by vomiting.

Question 3

Define : MEDIASTINITIS

Answer 3

Potentially life-threatening inflammation or infection of the mediastinum (thoracic space bordered by pleura, thoracic outlet, and diaphragm that contains many vital structures including the heart, great vessels, trachea, and esophagus).

Question 4

Define : MACKLER TRIAD (1)

Answer 4

Vomiting followed by lower chest pain and subcutaneous emphysema.

Question 5

Define : HAMMAN’S CRUNCH

Answer 5

“Mediastinal crunch,” which is a scratchy or crackly sound
heard with each heartbeat due to surrounding air confined within the mediastinum.

Question 6

Define : PLEURITIC

Answer 6

Associated with deep breathing, coughing, sneezing, or laughing.

Question 7

The most common cause of esophageal perforation is what?

Answer 7

actually iatrogenic, due to endoscopy.
However, these perforations are distinct from
the effort- and pressure-related rupture known as Boerhaave syndrome.

Question 8

Describe triad : Boerhaave syndrome (3)

Answer 8

Mackler triad
* vomiting
* lower chest pain
* subcutaneous emphysema

Question 9

Name CARDIOVASCULAR DDX of chest pain (4)

Answer 9

• ACS/STEMI
• Aortic dissection
• Cardiac tamponade
• Pericarditis

Question 10

Describe clinical presentation and dx study : Pericarditis

Answer 10

• Chest pain improved with leaning forward, pericardial friction rub, diffuse ST segment elevation
• Dx : ECG

Question 11

Describe clinical presentation and dx study : Aortic dissection

Answer 11

• Tearing chest pain radiating into back, symptoms involving two organ systems, can be hypotensive or hypertensive, ill appearing
• Dx study : CT angiogram

Question 12

Describe clinical presentation and dx study : Cardiac tamponade

Answer 12

• Tachycardia and shock, Beck triad, pulsus paradoxus, electrical alternans
• Dx : POCUS

Question 13

Name PULMONARY DDX of chest pain (3)

Answer 13

• EP
• Tension pneumothorax
• Pneumonia

Question 14

Describe clinical presentation and dx study : EP

Answer 14

• Pleuritic chest pain, dyspnea, tachycardia, tachypnea, hypoxia with relatively normal CXR, right heart strain on ECG, and POCUS
• Dx : D-dimer, CT angiogram

Question 15

Describe clinical presentation and dx study : Tension pneumothorax

Answer 15

• Penetrating trauma or blunt trauma, shortness of breath, tachypnea, shock, deviated trachea, unilateral breath sounds
• Dx : Clinical dx, POCUS, CXR

Question 16

Describe clinical presentation and dx study : Pneumonia

Answer 16

• Fever, cough, pleuritic chest pain, hypoxia, focal abnormal breath sounds
• Dx : Clinical diagnosis, CXR

Question 17

Name GI DDX of chest pain (5)

Answer 17

• Boerhaave syndrome
• Cholecystitis
• Pancreatitis
• GERD
• Esophageal spasm

Question 18

Describe clinical presentation and dx study : Boerhaave syndrome

Answer 18

• Acute onset chest pain, fever, tachypnea
• Dx : CT

Question 19

Describe clinical presentation and dx study : Cholecystitis

Answer 19

• Chest pain with RUQ or epigastric pain, anorexia, RUQ tenderness
• Dx : POCUS

Question 20

Describe clinical presentation and dx study : Pancreatitis

Answer 20

• Epigastric pain radiating to the back, vomiting, marked abdominal tenderness
• Dx : Elevated lipase, CT

Question 21

Describe clinical presentation and dx study : GERD

Answer 21

• Substernal burning chest pain, worse with lying down flat, worse at night, sour taste in mouth
• Dx : Clinical diagnosis

Question 22

Describe clinical presentation and dx study : Esophageal spasm

Answer 22

• Chest pain with dysphagia or odynophagia
• Dx : EGD, manometry

Question 23

Name MUSCULOSKELETAL DDX of chest pain (3)

Answer 23

• Muscle strain
• Costochondritis
• Breast pathology

Question 24

Describe clinical presentation and dx study : Muscle strain

Answer 24

• Chest pain worse with movements, sometimes pleuritic
• Dx : Physical exam

Question 25

Describe clinical presentation and dx study : Costochondritis

Answer 25

• Chest pain with tenderness to palpation near sternal border
• Dx : Physical exam

Question 26

Name beck Triad : Pericardial Tamponade

Answer 26

• hypotension
• jugular venous distention
• muffled heart sounds

Question 27

Describe tx : Pericardial Tamponade (5)

Answer 27

Initial treatment
* maximizing venous return with volume expansion
* elevating the legs
* and avoiding positive pressure ventilation if possible.

Definitive decompression of the pericardium can be achieved with
* pericardiocentesis
* or a surgical pericardial window.

Question 28

Treatment of uncomplicated pericarditis consists of what?

Answer 28

• nonsteroidal anti-inflammatory drugs (NSAIDs)
• colchicine
• close follow-up.

Question 29

Describe tx : EP (2)

Answer 29

• Treatment involves immediate anticoagulation with heparin or a direct oral anticoagulant.
• Shock or cardiac arrest from PE is an indication for** thrombolytic therapy**.

Question 30

Describe tx : Tension Pneumothorax (2)

Answer 30

Emergent treatment involves
* needle decompression of the hyper-resonant hemithorax with a large gauge needle or angiocath
* followed by tube thoracostomy.

Question 31

Name elements that predispose to reflux (3)

Answer 31

Caffeine, alcohol, and tobacco use all decrease lower esophageal sphincter
pressure and predispose to reflux.