Panoptos for Mental Probe 2

Question 1

___ of patients in ER for a chest problem will have acute coronary syndrome

Answer 1

10%

Question 2

___ of patients with symptoms of acute cardiac ischemia will have an MI

Answer 2

25%

Question 3

What is acute coronary syndrome

Answer 3

patients with an acute MI (heart attack) and/or unstable angina

Question 4

___ of patients in a primary care medical office have uynstable heart disease and need to have ____ _____

Answer 4

1.5%, emergency referral

Question 5

MEMORIZE
Cardiac chest pain, Ischemic
What are three diagnosis?

Answer 5

Stable angina, unstable angina (ACS), MI (ACS)

Question 6

MEMORIZE
Cardiac chest pain, non-ischemic
What are four diagnosis?

Answer 6

Pericarditis, Aortic dissection, Valvular heart disease, Arrythmias

Question 7

MEMORIZE
Non-cardiac chest pain, gastro-esophageal
What are three diagnosis?

Answer 7

GERD, peptic ulcer disease, esophageal spasm

Question 8

MEMORIZE
Non-cardiac chest pain, non-gastro-esophageal
What are four diagnosis?

Answer 8

Pneumothorax, pulmonary embolism, musculoskeletal, panic attack

Question 9

What does ischemic heart disease mean in layman’s terms

Answer 9

Heart is not getting enough oxygen and cells are dying

Question 10

GERD can closely mimic what?

Answer 10

heart attack, ACS

Question 11

Who should I call an ambulance for?

Answer 11

Chest pain and respiratory problems or abnormal vitals (eg. low BP)
may have an acutely unstable heart problem

Question 12

Most common to least common causes of heart pain

Answer 12

Musculoskeletal conditions
non-specific chest pain
GI disease
Stable CAD
psychosocial or psychiatric disease
Pulmonary disease
Other CV disease (pulmonary embolus/heart failure)
Unstable CAD

Question 13

MS conditions in patients in primary care office

Answer 13

29-36%

Question 14

GI disease causing chest pain in patients in primary care office

Answer 14

10-19%

Question 15

Stable CAD causing chest pain in patients in primary care office

Answer 15

8-10%

Question 16

psychosocial or psychiatric disease in patients in primary care office

Answer 16

8-17%

Question 17

Three procedures to investigate the heart

Answer 17

BP, pulse, auscultate heart (mitral valve while performing Valsalva)

Question 18

Procedures to investigate the Upper GI track

Answer 18

palpate or percuss upper quadrants with knees flexed

Assess epigastric region

Question 19

Procedures to investigate spine and body wall

Answer 19

Static and motion palpation of the cervical, thoracic spine (TLJ)
Palpate posterior ribs and back muscles
Palpate the chest wall (CS junctions, pectoralis, intercostals)

Question 20

Frequency of causes of chest pain in 204 non-acute patients

Answer 20

pericarditis - 9%
pleuritis - 2% 
pulmonary embolism - 2% 
lung cancer - 1.5%
aortic aneurysm - 1% 
aortic stenosis - 0.5%
herpes zoster - 0.5%

Question 21

Procedures to investigate the lungs

Answer 21

Observe respiratory rate
Observe breathing, use of accessory muscles
Palpate for fremitus
Auscultate the lungs

Question 22

What four signs indicate a patient who should be evaluated for myocardial infarction?

Answer 22

Chest pain, shortness of breath, dizziness/weakness/syncope, abdominal pain

Question 23

Of those who die of heart complications how early do they die?

Answer 23

within 2 hours of symptoms which is why new onset chest pain is so concerning

Question 24

What are four clues indicating high risk for Acute Coronary Syndrome?

Answer 24

Exertional chest pain
Pain radiating to one or both arms
Pain similar or greater than prior cardiac pain
Associated with nausea, vomiting, diaphoresis

Question 25

What are three clues that lower the likelihood of Acute Coronary Syndrome?

Answer 25

Pain that is pleuritic (breath)/positional/reproducible with palpation(BEST)/stabbing-knife Pain that is non-exertional Pain in a small inframammary part of the chest

Question 26

Location of chest pain is likely NOT

Answer 26

Above C3 or below T10

Question 27

Clinical Pearl for angina

Answer 27

suspect angina in any patient who describes discomfort above the waist that is provoked by exercise and relieved by rest

Question 28

MEMORIZE | Associated symptoms that make me worried about the heart

Answer 28

``` Dyspnea Dizziness Diaphoresis (shocky looking) Nausea (poor prognosis) Weakness (near) syncope Palpitations ```

Question 29

Modifiable risk factors for CVD

Answer 29

``` Overweight or obese - 65% LDL cholesterol >130mg/dl - 46% Physically inactive - 38% Hypertension - 26% Tobacco use - 25% Metabolic syndrome - 24% Pre-hypertension - 22% DM - 8% ```

Question 30

Factors that are non-modifiable for CVD

Answer 30

Male Family history Increased hsCRP (high pro-inflammatory levels) Hormone Replacement Therapy Increased coronary artery calcium (uses a specific CT scan)

Question 31

Ancillary studies for CAD risk factors

Answer 31

Lipid profile Glucose/HgB A1C/ 2 hour post load hsCRP Coronary artery calcium (CAC) (CAT scan. not a blood test) none of these tests diagnose HD, they are RISK factors

Question 32

Definition of stable angina

Answer 32

brief ischemic episodes without permanent heart damage

Question 33

Main criteria for diagnosing angina

Answer 33

Typical angina: Substernal chest discomfort with a characteristic quality and duration Provoked by exertion or emotional stress Relieved by rest or nitroglycerin Atypical angina: Meets 2 of the above criteria Noncardiac chest pain: Meets 1 of the above or none

Question 34

Ancillary studies for suspected angina

Answer 34

``` 12 lead resting EKG (often normal) Stress tests (EKG, echocardiogram, myocardial perfusion scintigraphy) - stress-- Chest radiograph (optional) ``` Angiogram (GOLD STANDARD)

Question 35

Qualities of unstable angina

Answer 35

``` Occurs at rest >10 minutes in length Nitro usually helps ST depression or elevation on EKG Unstable due to complicated atherosclerosis Prinzmetal type is due to vasospasm ```

Question 36

Qualities of stable angina

Answer 36

``` Exertion related <10 minutes in length Rest and nitro help ST depression on EKG Negative enzymes Due to atherosclerosis ```

Question 37

LR of nausea predicting acute MI

Answer 37

10

Question 38

LR of pain in both arms predicting acute MI

Answer 38

9.7

Question 39

LR of right arm pain predicting acute MI

Answer 39

7.3

Question 40

Cardiac red flags

Answer 40

Chest pain that completely stops a patient from activity

Question 41

PE features of MI

Answer 41

Third heart sound Hypotension (SBP <80) Pulmonary crackles Diaphoresis

Question 42

Clinical prediction rule to rule out CAD in chest pain patients

Answer 42

``` Women > 64, Men > 54 Known CAD, cerebrovascular disease, peripheral vascular disease Pain is worse with exercise Pain is not reproducible with palpation Patient assumes pain is cardiac ``` Each of the above is worth one point 98% with less than or equal to two will not have CAD, 23% with 3 or higher points will have CAD

Question 43

Ancillary tests for MI

Answer 43

``` 12 lead EKG (is likely changed) permanent change Troponins (breakdown protein from heart muscle) disappears in 24 hours Cardiac enzymes (CPK-MB, AST) ```

Question 44

Gold standard test for acute MI

Answer 44

angiography

Question 45

Causes of chest pain from heart that are not MI

Answer 45

Mitral valve prolapse | Pericarditis

Question 46

Mitral valve prolapse ancillary and big clue

Answer 46

Test with echocardiogram | Mid-systolic murmur or closing click

Question 47

Pericarditis big clues

Answer 47

non-pleuritic friction rub pre-cordial pain radiates to trapezius ridge *** aggravated by lying supine and relieved by bending forward characteristic Electrocardiogram changes

Question 48

Arrythmias that begin in the atrium or at the gateway to the lower chambers are ____ ____

Answer 48

supraventricular arrhythmias

Question 49

Types of supraventricular arrhythmias

Answer 49

atrial fibrillation atrial flutter paroxysmal supraventricular tachycardia (PSVT)

Question 50

Arrhythmias in the ___ ___ typically require urgent medical care and include ___ ___ and ___ ___.

Answer 50

lower chamber, ventricular tachycardia, ventricular fibrillation

Question 51

Patients with atrial fibrillation have a __ greater risk for stroke or peripheral embolism.

Answer 51

5X

Question 52

Oral anticoagulation is recommended in patients with ___ ___ who have had a ___ ___ _ ___ ___ ___. Currently approved anticoagulants include ___ ___ ___ ___.

Answer 52

atrial fibrillation, prior stroke or transient ischemic attack warfarin, dabigatran, rivaroxaban, and apixaban.

Question 53

Atrial fibrillation is more common in

Answer 53

Men than women and whites than blacks

Question 54

Atrial fibrillation can be associated with ___, ___, ___, and ___

Answer 54

hemodynamic dysfunction, tachycardia-induced cardiomyopathy, and systemic thromboembolism.

Question 55

Pericarditis ancillary tests

Answer 55

chest radiograph, CBC, blood chemistry, ESR

Question 56

causes of pleuritis

Answer 56

Viral, bacterial, secondary to pneumonia, systemic lupus

Question 57

If lupus is suspected test with

Answer 57

ANA | Anti-Nuclear Antibody

Question 58

Pleuritis clues and ancillary tests

Answer 58

Pleuritic pain, respiratory friction rub, fever/malaise | Ancillary: Chest radiograph, CBC, blood chemistry, ESR

Question 59

Tests for GERD

Answer 59

Acid suppression approach | Give a lot of PPI for a few weeks and if pain goes away then it is GERD. 40mg 2X a day

Question 60

Three questions for panic disorder

Answer 60

When you are nervous, how often do you think, “I am going to pass out”? During the last 7 days, including today, how much have you been bothered by pains in the chest? To what degree is your chest pain tiring or exhausting?

Question 61

In Cervicothoracic Angina (CTA) what is effective?

Answer 61

HVLA and STM