Chest Pain

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Chest Pain
2013-07-20 19:25:31
chest pain ACS Aortic dissection aortic stenosis esophagitis musculoskeletal panic attack pericarditis

Approach to chest pain
Show Answers:

  1. What are the 9 most likely differentials for chest pain?
    • 1. Acute coronary syndrome
    • 2. Acute dissection
    • 3. Aortic stenosis
    • 4. Esophagitis
    • 5. Musculoskeletal pain
    • 6. Panic Attack
    • 7. Pericarditis
    • 8. Pneumothorax
    • 9. Pulmonary embolism
  2. What is the classic presentation of ischemic chest pain?
    • 1. substernal pressure, tightness, or heaviness with radiation to the jaw, shoulders, back or arms
    • 2. Pain related to exertion and relieved by rest or nitroglycerin and may be accompanied by dyspnea, diaphoresis, nausea
    • 3. Pain typically lasts <20 mins. (if longer, suspect MI)
  3. What are the symptoms indicating unstable angina?
    • 1. Recent onset
    • 2. Increasing symptoms of chest discomfort occurring at rest without elevation of biomarkers,  eg Troponin and creatine kinase
  4. What are the most powerful clinical features that increase probability of MI?
    • 1. Chest pain that radiates to both arms (positive likelihood ratio = 7.1)
    • 2. S3 (positive likelihood ratio = 3.2)
    • 3. hypotension (positive likelihood ratio = 3.1)
  5. How does prinzmetal angina present?
    • prinzmetal angina - coronary artery vasospasm
    • 1.  Rest pain similar to angina
    • 2.  ECG - ST-segment elevation

    Can also be from cocaine use.
  6. Symptoms:
    1. Sudden onset of sharp, stabbing substernal chest pain with radiation along the trapezuis ridge.
    2. pain worse with inspiration and lying flat
    pain alleviated with sitting and leaning forward
    Acute pericarditis
  7. What symptoms can accompany acute pericarditis?
    • respiratory tract infection
    • fever
  8. What percentage of cases does friction rub occur in pericarditis?
    What does the classic rub consist of?

    atrial systole, ventricular systole, diastole
  9. What will an electrocardiogram show during pericarditis?
    • 1. diffuse ST-segment
    • 2. PR-segment depression
  10. Patient presents with abrupt onset of severe, sharp, or "tearing" chest pain radiating to the abdomen, or back pain.  What is it?
    aortic dissection
  11. What are the physical exam findings of aortic dissection?
    asymmetric pulses on palpation of the carotid, radial, or femoral arteries
  12. A patient presents with "tearing" chest pain and asymmetric pulses.  What next?
    • Get a CXR.
    • If wide mediastinum on chest radiography, then image:
    • computed tomography of chest
    • MRI
    • TEE
    • aortic root angiography
  13. What are the symptoms, physical exam findings, and imaging that indicate aortic stenosis?
    • exertional chest pain
    • dyspnea
    • palpatations
    • exertional syncope
    • all due to decreased cardiac output

    • Phys exam
    • systolic, crescendo-decrescendo murmur best heard at second right intercostal space with radiation to carotids

    BEST seen on TTE
  14. A young women presents to the ED with angina-like chest pain.  What's the most likely diagnosis? What are further characteristics?
    Syndrome X

    anginal symptomsSt-segment depression on exercising testing and normal coronary arteries on angiography
  15. A patient presents with acute pleuritic chest pain, dyspnea, and, less often, cough and hemoptysis.  What is the most likely diagnosis?
  16. What are the risk factors for PE?
    Wells score.
  17. A patient's physical exam findings show tachycardia, tachypnea, wheezing; right-sided S3 and right ventricular heave.  What's this indicative of?
  18. What are the symptoms and physical findings found in chest pain associated with pneumonia?
    • fevers, chills, cough, purulent sputum, dyspnea
    • wheezing, crackles and signs of consolidation such as dullness to percussion, egophony (E to a transition), and bronchophony (ninety nine)
  19. What are the physical exams findings with someone with a pneumothorax?
    diminished breath sound on side of pneumo

    tracheal deviation to the opposite side of pneumo

  20. What kind of procedures and labs should be considered if chest pain is thought to be caused by a pulmonary problem?
    • Positive Well's score
    • CXR
    • People with dyspnea: blood gas, pulse ox
    • moderate to high suspicion of PE: helical CT or ventilation/perfusion lung scan with doppler exam of lower extremities
    • D-dimer if well's score is moderate
  21. A patient has chest pain that is worse when lying down and after meals and sometimes awakes patients from sleep.  Whta is the most likely diagnosis?
  22. What are the physical exam findings that are associated with GERD?
    • wheezing
    • halitosis
    • dental erosions
    • pharyngeal erythema
  23. What is an appropriate first step in diagnosis and treatment of GERD?
    4-6 weeks on a proton pump inhibitor
  24. What's the most common cause of musculoskeletal associated chest pain?

    others arthritis, fibromyalgia
  25. A patient comes in complaining of sweating, trembling, shaking, sensations of choking, shortness of breath, nausea, and dizziness with chest pain.  Cardiovascular and Pulmonary exam unremarkable.  Diagnosis?
    panic attacks