PDII E3: Chest Pain

In a patient presenting w/ chest pain, assume ____ until proven otherwise

MI

What are 3 important questions to ask when assessing chest pain?

Is the chest discomfort substernal?

Are the sx precipitated by exertion?

Does rest or nitroglycerin provide prompt relief?

What conditions present with CP typically behind the sternum?

acute MI and angina

what conditions present w/ epigastric pain that radiates to the chest?

GERD and gastric ulcer

In what condition would CP radiate to the neck/jaw?

acute MI

In what condition would CP radiate to the throat and down the back?

esophageal pain

In what condition would CP radiate between the shoulder blades or down to the abdomen?

dissecting aneurysm

Heavy/crushing pain is seen w/ _____

acute MI

Burning pain is ______

esophageal

Tearing pain is seen w/ _____

aortic aneurysm

Sharp/stabbing pain is _____

pleuritic pain

If CP improves w/ antacids, what conditions should you consider?

esophagitis and GERD

If CP improves w/ nitroglycerin spray, what conditions should you consider?

angina and esophageal spasm

If CP improves w/ NSAIDs, what conditions should you consider?

musculo/skeletal

What conditions should be considered if CP is worse with breathing?

pleurisy, costochondritis, fractured rib, PTX

what conditions should be considered if CP worsens w/ movement?

pericarditis

what conditions should be considered if CP worsens w/ bending, lifting, straining, etc?

esophageal reflux or spasm

What syndrome is associated w/ an increased risk of dissecting aneurysm?

marfans

CP and acid/bitter taste in mouth?

reflux esophagitis

CP and coughing up blood?

PE

CP, fever, and yellow/green phlegm?

PNA

CP and rash in area of pain?

herpes zoster

what is the most important diagnosis to r/o?

myocardial infarction

myocardial O2 demand must _____ O2 supply

=

What are examples of modifiable risk factors for an MI?

• hypercholesterolemia

• smoking

• HTN

• physical inactivity

• low HDL < 40

• DM

• truncal obesity

what are examples of non modifiable risk factors for MI?

• age

  • M ≥ 45

  • F ≥ 55

• FHx

  • M < 55

  • F < 65

What sx are associated w/ MI?

• angina/CP

• dyspnea/SOB

• arm pain

• diaphoresis

• nausea

What PE findings might you see w/ an MI?

• inc HR & BP

• S4

• precordial bulge

• systolic murmur

• vomiting

• Levines sign

What is Levines sign?

clenched fist held over chest

what EKG changes would you see w/ an MI?

• ST depression or T inversion (25% pts)

• ST elevation w/ reciprocal changes (75%)

• Q waves (indicate damage)

What should you do next in a pt w/ suspected MI if there are no EKG changes?

observe for 6-12 hrs and order serial EKGs

what tests should you do after ordering serial EKGs and observing a pt w/ suspect MI?

graded stress test or nuclear scan & echo/LV imaging

Decreased EF is a sign of ____

CHF

What are classic hallmark signs of angina?

• sudden onset w/ exertion, stress, or large meal

• squeezing heaviness, pressure, more discomfort than pain

• radiation (jaw, neck, shoulder, etc)

• diaphoresis, nausea, dyspnea

• 2-20 min duration, prompt relief w/ nitro

Ischemic pain > ____ min suggests MI

5 min

What kind of angina?

• substernal chest discomfort precipitated by exertion

• sx resolve promptly w/ rest or nitro and does not change over course of wks

• risk factors for CAD

stable

What kind of angina?

• intensity, frequency, and duration is changed

• no longer predictable

• pain precipitated by less activity or of longer duration

• pain at rest or new onset

unstable

Angina caused by a mismatch bt myocardial O2 supply and demand is usually a product of ____

coronary stenosis

Besides exercise, what other factors can induce angina?

cold weather, extreme moods (anger, stress), large meals

what other presentations besides CP can angina have?

• dyspnea

• nausea or indigestion

• pain other than chest (jaw, neck, teeth, back, abdomen)

• palpitation

• syncope

• diaphoresis

• weak/fatigue

What population are you likely to see prinzmetal angina in?

younger females

Prinzmetal angina almost always occurs at _____

rest(often night or early morning)

What kind of angina is secondary to vasospasm or narrowing of coronary arteries?

prinzmetal

What causes prinzmetal angina?

contraction of smooth muscle tissue in vessel walls rather than atherosclerosis directly

which type of angina would you treat with CCBs, nitrates, and lifestyle changes?

prinzmetal

which type of angina would require emergency treatment (anti platelets, anticoagulants, revascularization)?

unstable

which type of angina would you treat with medications such as nitrates, BBs, and life style changes?

stable

A diagnosis of esophageal disease is based off of ____

• clinical presentation

• trial antacids

• EGD

• 24 hr pH monitoring

A diagnosis of a PE w/ pleuritic pain is based off ____

• H&P

• CXR

• chest CTA

• D Dimer

When would you order a gram and acid fast stain?

if productive cough is present

How would pneumococcal PNA and TB w/ CP present?

acute pleuritic pain

What might you see on an EKG in pericarditis?

ST elevation throughout, no T inversion, PR depression

What has an improved sensitivity for myocardial muscle damage after an AMI m peaks around 24 hrs but returns to baseline w/in 2-3 days?

CK-MB

What is a non-specific enzyme that is released after any skeletal damage, peaks at 6-8 hrs and returns normal In 20-36 hrs?

myoglobin

what has 90% sensitivity for MI 8 hours after onset of symptoms and remains in serum for 14-15 days?

trop I

what has 84% sensitivity for MI 8 hours after onset of symptoms and remains in serum for 14-15 days?

trop T

What are contraindications to morphine?

allergy or SBP < 100

what are contraindications to nitroglycerin?

SBP < 100 or taking viagra

What is MONA/FONA?

• morphine/fentanyl

• oxygen (<94%)

• nitroglycerin

• ASA 325 mg

What kind of patient might not experience ANY discomfort during an MI?

diabetic

what type of patient would have an atypical presentation of an MI- dyspnea, GERD like sx, R sided CP, or jaw/arm pain ONLY?

female

any chest pain in a _____ MUST be evaluated for a possible cardiac cause.

woman

What should you suspect in a patient w/ asymmetrical peripheral pulses or BP?

aortic dissection

What should you suspect in a patient w/ tachycardia, tachypnea, and feeling of impending doom?

pulmonary embolus

Can a single biomarker or just an EKG r/o an NSTEMI?

no

what should you do if you suspect ACS?

repeat EKG w/ changes in the pt