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Block 1 Year 3 > Week 5 - Chest Pain > Flashcards

Week 5 - Chest Pain Flashcards

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1
Q

What is atherosclerosis ?

A

Chronic inflammatory process triggered by accumulation of cholesterol-containing, low-density lipoproteins (LDL) in the arterial wall

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2
Q

What is the most likely diagnosis of…

“Sudden onset pleuritic pain either left or right sided with associated dyspnoea and syncope” ??

A

Pneumothorax

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3
Q

What is the most likely diagnosis of…

“Pain typically persistent (days or longer), worsened with passive and active motion and sometimes reproducible chest tenderness” ?

A

Musculoskeletal pain

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4
Q

What is the most likely diagnosis of…

“Exertional pain/discomfort in the centre or left side of chest, throat, neck or jaw, relieved by rest or GTN within a few minutes. May radiate to neck, jaw or left arm. Sometimes there may not be any pain but breathlessness” ?

A

Angina

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5
Q

What is the most likely diagnosis of…

“Constant or intermittent central pleuritic sharp pain often aggravated by position (classically worse lying down, and relieved by sitting or leaning forward)” ?

A

Pericarditis

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6
Q

What is the most likely diagnosis of…

“Sudden onset pleuritic pain with associated dyspnoea and tachycardia. Sometimes mild fever, haemoptysis and syncope” ?

A

Pulmonary Embolism

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7
Q

What is the most likely diagnosis of…

“Recurrent, vague epigastric discomfort, that is relieved by food, antacids, or both” ?

A

Peptic ulcer disease

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8
Q

List some cardiovascular conditions that would cause central chest pain …

A
  • angina
  • acute coronary syndrome
  • pericarditis
  • aortic dissection
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9
Q

List some respiratory conditions that would cause central chest pain …

A
  • PE
  • Pleurisy
  • Pneumonia
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10
Q

List some musculoskeletal conditions that would cause central chest pain …

A
  • rib fracture
  • muscle injury
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11
Q

Name a skin condition that would cause central chest pain …

A

Shingles

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12
Q

List some gastrointestinal conditions that would cause central chest pain …

A
  • peptic ulcer disease
  • oesophageal spasm
  • oesophageal rupture
  • gall stones
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13
Q

What are the conditions included under the umbrella term of Acute Coronary Syndrome ?

A
  • ST elevation MI (STEMI)
  • non ST elevation MI (NSTEMI)
  • unstable angina
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14
Q

What are the symptoms of Acute Coronary Syndrome ?

this includes: STEMI, NSTEMI, unstable angina

A
  • acute, crushing pain
  • pain radiation to jaw or arm
  • exertional pain, relieved by rest
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15
Q

What are the signs of Acute Coronary Syndrome ?

this includes: STEMI, NSTEMI, unstable angina

A
  • sinus tachycardia
  • a new murmur (often mitral regurgitation = pan-systolic)
  • Xanthelasma
  • tar staining on fingers
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16
Q

What are the risk factors for Acute Coronary Syndrome ?

this includes: STEMI, NSTEMI, unstable angina

A
  • hypertension
  • hypercholesterolaemia
  • diabetes
  • cigarette smoking
  • lack of physical activity
  • obesity/overweight
  • poor diet
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17
Q

What are the symptoms of stable angina ?

A
  • exertional pain/discomfort (central/left sided in chest, throat, neck, jaw)
  • relieved by rest or GTN within a few mins
  • radiate to neck, jaw, left arm
  • sometimes no pain, but breathlessness
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18
Q

What are the signs of stable angina ?

A

Examination usually normal except indication of risk factors e.g tar staining, xanthelasma…

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19
Q

What are the risk factors for stable angina ?

A
  • hypertension
  • hypercholesterolaemia
  • diabetes
  • cigarette smoking
  • lack of physical activity
  • obesity/overweight
  • poor diet
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20
Q

What are the symptoms of thoracic aortic dissection ?

A
  • sudden, tearing pain radiating to back
  • some patients have syncope, stroke, leg ischaemia
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21
Q

What are the signs of thoracic aortic dissection ?

A
  • pulses paradoxus
  • different BP in both arms
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22
Q

What are the risk factors for a thoracic aortic dissection ?

A
  • hypertension
  • known aortic aneurysm
  • bicuspid aortic valve
  • Marfan’s syndrome
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23
Q

What are the symptoms of myocarditis ?

A
  • fever
  • dyspnoea
  • fatigue
  • chest pain (if myopericarditis)
  • maybe pleuritic chest pain
  • recent viral/other infection
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24
Q

What are the signs of myocarditis ?

A
  • fever
  • tachycardia
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25
What are the risk factors for myocarditis ?
Recent viral illness
26
What are the symptoms of pericarditis ?
- constant or intermittent sharp chest pain - pain often aggravated by breathing or position - classically worse when lying down, better sitting or lent forwards
27
What are the signs of pericarditis ?
- tachycardia - pericardial rub
28
What are the risk factors for pericarditis ?
Recent viral illness
29
What are the symptoms of PE ?
- sudden onset pleuritic pain, associated with tachycardia and SOB - *sometimes* mild fever, haemoptysis and syncope
30
What are the signs of PE ?
- tachycardia - swollen leg *(unilateral, red, sore and hot)*
31
What are the risk factors for PE ?
- immobility for long time period - long haul flight - inherited blood clotting disorders - recent surgery or broken bone injury *(risks are higher after both of these)* - active/history of cancer - acute medical illness *(DKA, sepsis)* - pregnancy
32
What are the symptoms of tension pneumothorax ?
- significant SOB - hypotension - raised JVP
33
What are the signs of tension pneumothorax ?
- tracheal deviation - unilateral diminished breath sounds - hyperresonance on percussion
34
What are the risk factors for tension pneumothorax ?
- male - smoking - lung disease *(e.g emphysema)* - marfan’s syndrome - genetic
35
What are the symptoms of pneumonia ?
- pleuritic chest pain - fever - productive cough - purulent sputum
36
What are the signs of pneumonia ?
- bronchial breathing - crepitations - reduced air entry
37
What are the risk factors for pneumonia ?
- older age - infective contacts - underlying chronic lung disease - immunosuppression
38
What are the symptoms of pleurisy ?
- pleuritic chest pain *(exacerbated by cough)* - *may have* preceding pneumonia, PE or viral resp infection
39
What are the signs of pleurisy ?
Pleural rub
40
What are the risk factors for pleurisy ?
Recent infection
41
What are the symptoms of oesophageal rupture ?
Sudden, severe pain following vomiting or medical instrumentation *(e.g imagining, feeding tubes etc)*
42
What are the signs of oesophageal rupture ?
severe epigastric pain with guarding and rigidity
43
What are the risk factors for oesophageal rupture ?
- gastroscopy /imagining with throat entry - transoesophageal echocardiography - catheter ablation for AF
44
What are the symptoms of peptic ulcer disease ?
- recurrent vague epigastric discomfort - relieved by food, antacids or both
45
What are the signs of peptic ulcer disease ?
epigastric discomfort
46
What are the risk factors for peptic ulcer disease ?
- hypertension - hypercholesterolaemia - diabetes - cigarette smoking - lack of physical activity - obesity/overweight - poor diet
47
What are the symptoms of pancreatitis ?
- epigastric pain worse when lying down, relieved leaning forward - vomiting - upper abdominal tenderness
48
What are the signs of pancreatitis ?
- epigastric pain - jaundice
49
What are the shriek factors for pancreatitis ?
- high alcohol intake - raised BMI - female
50
What are the symptoms of GORD ?
- recurrent burning pain - pain radiating from epigastrium to throat - Exacerbated by lying/bending down - Relieved by antacids
51
What are the signs of GORD ?
- mild epigastric tenderness
52
What are the risk factors for GORD ?
- raised BMI - stress/anxiety - smoking - triggers: coffee, chocolates
53
What are the symptoms of MSK pain ?
- often suggested by history - persistent pain, worsened with passive and active motion
54
What are the signs of MSK pain ?
Diffuse of focal tenderness
55
What are the risk factors for MSK pain ?
- recent injury - heavy lifting - osteoporosis
56
What are the symptoms of shingles ?
- sharp, band-like in thorax unilaterally - classic linear, vesicular rash - pain pain may precede rash by several days
57
What are the signs of shingles ?
Rash on chest with vesicles
58
What are the risk factors for shingles ?
- immunosuppression - older age
59
What is a normal heart rate ?
Between 60-100 bpm
60
What are the risk factors for coronary heart disease (CHD) ?
- age - ethnicity - male gender - family history - smoking - obesity - exercise - diabetes - hyperlipidaemia - hypertension - inflammatory disease
61
Is the mortality risk following an MI higher in men or women ?
Women *due to biases and inequalities of treatment*
62
Why are women more likely to die after an MI than men ?
**inequalities and biases** - less likely to have risk factors recorded - less likely to receive aspirin - less likely to undergo investigation - underepresentation in clinical trials - women present slightly differently and it isn’t known as well as male signs of MI
63
What % of people survive a heart attack ?
70%
64
What is involved in clinical assessment for stable angina ?
- history of chest pain - risk factors - OBs/NEWS - 12 lead ECG - bloods (inc. diabetes screening)
65
What are the diagnostic features of typical angina chest pain ?
- constricting discomfort in **chest, shoulders, neck and arms** - **worse on exertion** - **relieved by GTN or rest** in 5 mins
66
Why is stable angina exertional pain ?
- atheroma narrows coronary artery/vessels - on exertion, myocardial demand rises - supply cannot meet demand
67
What is the first investigation for all patients experiencing chest pain for longer than 15 mins ?
**12 lead ECG** to exclude ST elevation
68
What is the next investigation after an ECG for patients with ongoing chest pain and no findings of ST elevation on the ECG ?
Troponin testing
69
After an ECG showing **no ST elevation**, what is indicated if the 6hr troponin test comes back… A) elevated ? B) not elevated ?
Elevated = NSTEMI Not elevated = Unstable Angina
70
What is the immediate investigation plan for patients with acute chest pain ?
1. **12 lead ECG** *(looking for ST elevation)* 2. **6hr troponin test** *(if no elevation found)*
71
Which type of troponins are looked for in the 6hr troponin test ?
Troponin **T** Troponin **I**
72
What happens to a patient found to have no ST elevation, but raised Troponin T or I ?
*considered high risk* - admitted to coronary care unit - undergo **angiography and/or angioplasty**
73
What tool is used to gauge a patients risk of cardiovascular events in the next 10 years ?
QRISK3 score
74
What information does the QRISK3 score need in order to calculate a patients risk of cardiovascular events within 10 years?
- age - gender - smoking status - history of diabetes, hypertension - family history of cardiovascular problems - physical exercise status - diet - BMI - cholesterol As well as… - migraine - chronic kidney disease (inc. stage 3 CKD) - corticosteroids - SLE - atypical antipsychotics - severe mental illness - erectile dysfunction - systolic BP variability
75
What does GTN stand for?
Glyceryl trinitrate *(spray)*
76
Can a normal ECG rule out acute coronary syndrome ?
No ! NSTEMI and unstable angina can often have a normal ECG, as the pain has subsided by the time it’s performed
77
What test is required to rule out acute coronary syndrome in patients with chest pain but a normal ECG ?
Cardiac Troponin test
78
What troponin result would indicate MI ?
A 50% rise or fall in troponin within 3-6 hours after the onset of chest pain
79
What is the treatment for an acute STEMI ?
Dual anticoagulant therapy of aspirin paired with: - **prasugrel** if not already taking oral anticoagulant *(offer ticagrelor or clopidogrel as alternatives if the patient has a high risk of bleeding)* - **clopidogrel** if already taking an anticoagulant
80
Are STEMIs or NSTEMIs more common ?
NSTEMI
81
What treatment medications are offered to patients following an MI ?
- ACE inhibitors - dual antiplatelet therapy *(aspirin + another anticoag e.g clopidogrel)* - beta blockers - statins
82
What might acute chest pain paired with breathlessness indicate ?
A respiratory cause e.g PE, Pneumothorax
83
What might acute chest pain paired with nausea, vomiting, pallor and sweating indicate ?
Acute MI
84
What might acute chest pain paired with a productive cough indicate ?
- Chest infection e.g pneumonia - Pleurisy
85
What might acute chest pain paired with fever and non-specific viral symptoms indicate ?
- pericarditis - myocarditis
86
What might acute chest pain paired with fever, night sweats and weight loss indicate ?
Malignancy with lung or bone metastasis causing chest pain
87
What might acute chest pain paired with palpitations indicate ?
Arrhythmia
88
What might acute chest pain paired with dizziness and syncope indicate ?
Serious acute conditions - tachyarrythmias - MI - aortic dissection - PE - tension pneumothorax *dizziness and syncope are red flag symptoms*
89
How is the pain described in most patients with an aortic dissection ?
- from chest, migrating to the back - from abdomen, migrating to one or more limbs or the neck - severe - not affected by exertion, movement or position
90
What are the most common clinical signs for aortic dissection ?
- pulsus paradoxus - distended neck veins - muffled heart sounds - pulse deficits *(a difference of 20mmHg or more in BP between left and right arms)*
91
What are some risk factors for aortic dissection ?
- hypertension - atherosclerosis - aortopathies e.g bicuspid aortic valve disease - connective tissue disorders - hereditary conditions e.g Marfan’s
92
What is the first line investigation if aortic dissection is suspected ?
Urgent contrast thoracic aortogram
93
What is type A aortic dissection ?
Dissection involving the ascending aorta
94
What is type B aortic dissection ?
Dissection not including the ascending aorta
95
What is the immediate treatment for type A aortic dissection ?
Surgery
96
What is the immediate management of type B aortic dissection ?
Admitted for urgent BP control and monitoring in a coronary high dependency care unit

Block 1 Year 3 (7 decks)

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