1 Given a patient with undefined chest pain, take an adequate history to make a specific diagnosis (e.g., determine risk factors, whether the pain is pleuritic or sharp, pressure, etc.).
Hx: OPQRSTAAA approach:
- Onset/duration: sudden vs gradual? Hours vs days? Previous similar symptoms? Progression? Course? Pleuritic?
- Position / Location
- quality: crushing, pressing, squeezing, stabbing, tightening
- Radiation – both arms > L arm for MI, to jaw, epigastric region, retrosternal (dissection)
- Severity – use scale 0-10 (not useful but grants a point on OSCE)
- Aggravating / Alleviating factors: better or worse with exertion / rest , position (better sitting up, worse lying down = ddx: GERD or pericarditis), inspiration / expiration (pleuritic – PE)
- Associated symptoms: dyspnea, orthopnea, PND, edema (CHF), diaphoresis, cough+/- hemoptysis, SOB (PE), N or V, abdo pain
S/Sx of MI “PULSE”
- Persistent CP
- Upset stomach
- Lightheadedness
- SOB
- Excessive sweating
Risk factors:
- Diabetes,
- Smoking, EtOH, age
- HyperLipids
- Fm Hx (premature CAD – men <55 or women <65)
- Previous CV dz
2 Given a clinical scenario suggestive of life-threatening conditions (e.g., pulmonary embolism, tamponade, dissection, pneumothorax), begin timely treatment (before the diagnosis is confirmed, while doing an appropriate work-up).
Common DX:
- ISCHEMIA, pneumonia, MSK pain, PE, GERD, psych
Life threatening dx:
- Massive PE: pleuritic c/p, dyspnea, ↓ O2 sat, anxiety, tachycardia
- ECG – RBBB, S1Q3T3, R heart strain
- CXR – normal to Westermark or Hamptom hump
- Esophageal rupture
- Fever, dyspnea, subcutaneous emphesema, tachycardia, hematemesis
- CXR – pneumomediastium
- Consult surgery
- Tamponade
- Dyspnea, HoTN, tachycardia, C/P
- ↑JVP, narrowed pulse pressure, muffled heart sounds
- dx with eCG + echo & Tx with pericardiocentesis
- Massive MI
- Aortic dissection: sudden severe “tear” pain radiate to back
- CXR = widened mediastinum & >20mmHg diff in BP on R vs L
- CT to confirm and OR if unstable
- Tension Pneumothorax
- pleuritic c/p, dyspnea, tachycardia, tachypnea, hypoxia, DEVIATED trachea
- CXR – lung marking not extend to periphery
- Tx with chest tube / need decompression if urgent
Tx: ABC, OMIP, Cross match blood & surgical management
3 Rule out ischemic heart disease.*Note: *See the key features on ischemic heart disease.
4 Given an appropriate history of chest pain suggestive of herpes zoster infection, hiatal hernia, reflux, esophageal spasm, infections, or peptic ulcer disease:
a) Propose the diagnosis.
b) Do an appropriate work-up/follow-up to confirm the suspected diagnosis.
Singles
- Clinical dx:
- Tingling sensation –> vesicular rash following a dermatome (don’t cross midline)
- Unilateral vesicular rash in dermatomal pattern
- Risks: immunocompromised, cancer, old, HIV
- Acyclovir within 72hr of rash, contagious until lesions crusted.
PUD
- Nausea, bloating, fullness, early satiety, distention, belching
- Dyspepsia ± UGIB (hematemesis, melena)
- heart burn 1-3hr postprandial (vs gastritis with burning/pain immediate after ingestion), improve with food
- RED Flags – Vomiting, Bleeding/anemia, Abd mass / unexplained Wt loss, Dysphagia
- Risks: H. Pylori, stress, Meds: NSAIDs/ASA/Bisphosphonate/CCB, smoking, caffeine, xs EtOH, steroid use
- Ix: CBC, FOB
- H Pylori testing / urea breath test if <50, no red flags, no NSAIDs/ASA/GERD
- no ppi x 2 week before the test; usually Test before PPi Tx
- Gastroscopy if >50 with new symptoms or Alarm features, fail repeated Tx
- H Pylori testing / urea breath test if <50, no red flags, no NSAIDs/ASA/GERD
- Tx: Lifestyle modification, modify meds, PPi, triple threapy (see Antibiotics post) if H Pylori
- Urea breath test for cure 30d after Tx
- Complication: H Pylori can develop into adenocarcinoma (1% of MALT lymphoma)
GERD / Hiatal hernia
- Frequent heartburn, dysphagia, relief with antacid
- Gastroscopy > Upper GI series / barium swallow
- Trial of PPi + lifestyle modification
- Complications: Esophageal stricture, ulcer / Barrett’s esophagus (pre-cancerous)
Esophageal Spasm
- Dysphagia (liquid and solid) + c/p
- Barium swallow / manometry
- Tx with anticholingergics / buscopan, nitrate, CCB, botox injection
5 Given a suspected diagnosis of pulmonary embolism:
a) Do not rule out the diagnosis solely on the basis of a test with low sensitivity and specificity.
b) Begin appropriate treatment immediately.
Well Score
< 4 PERC if <50yo / D-dimer
>3 CT PE or VQ scan (pregnancy or young female)
- Suspected DVT = 3
- Alt dx of PE less likely = 3
- HR>100bpm = 1.5
- Prior VTE = 1.5
- Immobilization / Sx within last 4 wk = 1.5
- Active Malignancy = 1
- Hymoptysis = 1
Tx: Anticoagulation
- Warfarin with LMWH / Heparin bridging for 5 days + 2 days of Warfarin at therapeutic level
- Consider thrombolytics if massive PE (consult ICU)
Preparing for the CCFP Exam 2015 
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