Chest Pain

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
  • 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)
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Posted in 13 Chest Pain, 99 Priority Topics, Cancer, FM 99 priority topics

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CCFP ExamApril 30th, 2015
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