Approach To Chest Discomfort From Harrison's

Front 1

list serious ddx of chest discomfort

Back 1

acute ischemic heart disease
aortic dissection
tension pneumothorax
pulmonary embolism

Front 2

what are the most common diagnoses of chest discomfort in pts without MI?

Back 2

42% gastroesophageal dz: gastric reflux, esophageal motility disorder, peptic ulcer, gallstones

31% ischemic heart dz
28% chest wall syndrome

4-1% : pericarditis, pleuritis/pneumonia, PE, lung cancer, aortic aneurysm, aortic stenosis, herpes zoster

Front 3

when does myocardial ischemia happen?

Back 3

when the oxygen supply to the heart is insufficient to meet metabolic needs. This mismatch can result from a decrease in oxygen supply, a rise in demand, or both.

Front 4

what is The most common underlying cause of myocardial ischemia? what triggers it?

Back 4

obstruction of coronary arteries by atherosclerosis; in the presence of such obstruction, transient ischemic episodes are usually precipitated by an increase in oxygen demand as a result of physical exertion or psychological stress, fever, or large meals or from compromised oxygen delivery due to anemia, hypoxia, or hypotension

Front 5

how does Ventricular hypertrophy due to valvular heart disease, hypertrophic cardiomyopathy, or hypertension can predispose the myocardium to ischemia?

Back 5

because of impaired penetration of blood flow from epicardial coronary arteries to the endocardium.

Front 6

how is The chest discomfort of myocardial ischemia, a visceral discomfort, usually described?

Back 6

heaviness, pressure, or squeezing, burning and aching. dyspnea or a vague sense of anxiety. The word "sharp" is sometimes used by patients to describe intensity rather than quality.

Front 7

what is major diff b/w angina, unstable angina and MI?

Back 7

duration!
angina: 2-10 min
unstable angina: 10-20 min
MI: > 30 min

Front 8

where is the location of angina, unstable angina and MI?

Back 8

Retrosternal, often with radiation to or isolated discomfort in neck, jaw, shoulders, or arms—frequently on left

Front 9

what precipitates angina and unstable angina?

Back 9

Precipitated by exertion, exposure to cold, psychologic stress

Front 10

what heart sounds might you hear during angina and unstable angina?

Back 10

S4 gallop or mitral regurgitation murmur during pain

Front 11

what is the main difference between angina and unstable angina?

Back 11

unstable angina occurs with low levels of exertion or even at rest

Front 12

what can be associated with an MI?

Back 12

heart failure or arrhythmia

Front 13

what are the quality and location of symptoms of aortic stenosis?

Back 13

same as angina

Front 14

what heart sounds do you hear with aortic stenosis?

Back 14

Late-peaking systolic murmur radiating to carotid arteries

Front 15

what is time course of pericarditis?

Back 15

Hours to days; may be episodic

Front 16

what is quality and location of discomfort with pericarditis?

Back 16

sharp pain Retrosternal or toward cardiac apex; may radiate to left shoulder

Front 17

what relieves pericarditis pain?

Back 17

May be relieved by sitting up and leaning forward

Front 18

what heart sound do you hear with pericarditis?

Back 18

Pericardial friction rub

Front 19

what is the time course of an aortic dissection?

Back 19

Abrupt onset of unrelenting pain

Front 20

what's the quality and location of pain from aortic dissection?

Back 20

Tearing or ripping sensation; knifelike Anterior chest, often radiating to back if dissects into descending aorta, between shoulder blades
most common symptom is sudden onset of severe, sharp pain.

Front 21

what medical conditions are associated with an aortic dissection?

Back 21

Associated with hypertension and/or underlying connective tissue disorder, e.g., Marfan syndrome

Front 22

what are the associated signs of an aortic dissection?

Back 22

Murmur of aortic insufficiency, pericardial rub, pericardial tamponade, or loss of peripheral pulses, cerebrovascular accident, or paraplegia

Front 23

what is the time course of a PE?

Back 23

Abrupt onset; several minutes to a few hours

Front 24

what's the quality and location of a PE?

Back 24

Pleuritic Often lateral, on the side of the embolism

Front 25

what symptoms are associated with a PE?

Back 25

Dyspnea, tachypnea, tachycardia, and hypotension, hemoptysis

Front 26

what's the time course for pulmonary hypertension?

Back 26

Variable

Front 27

what's the quality and location of discomfort in pulmonary hypertension?

Back 27

Substernal pressure

Front 28

what are the associated symptoms of pulmonary hypertension?

Back 28

Dyspnea, signs of increased venous pressure including edema and jugular venous distention

Front 29

what's the time course for pneumonia or pleuritis?

Back 29

variable

Front 30

what's the quality and location of discomfort for pneumonia or pleuritis?

Back 30

pleuritic Unilateral, often localized

Front 31

what symptoms are associated with pneumonia and pleuritis?

Back 31

Dyspnea, cough, fever, rales, occasional rub

Front 32

what's the time course for a spontaneous pneumothorax?

Back 32

Sudden onset; several hours

Front 33

what's the quality and location of discomfort for a spontaneous pneumothorax?

Back 33

pleuritic. Lateral to side of pneumothorax

Front 34

what symptoms are associated with spontaneous pneumothorax?

Back 34

Dyspnea, decreased breath sounds on side of pneumothorax

Front 35

what's the time course of esophageal reflux?

Back 35

10–60 min

Front 36

what's the quality and location of discomfort in esophageal reflux?

Back 36

burning, Substernal, epigastric

Front 37

what symp are ass w/ esophageal reflux?

Back 37

Worsened by postprandial recumbency

Relieved by antacids

Front 38

what's time course for esophageal spasm?

Back 38

2–30 min

Front 39

what's quality and location for discomfort from esophageal spasm?

Back 39

retrosternal Pressure, tightness,
burning
*can mimic angina

Front 40

time course for peptic ulcer?

Back 40

Prolonged

Front 41

quality and location of discomfort with peptic ulcer?

Back 41

Epigastric, substernal burning

Front 42

what signs are ass with peptic ulcer?

Back 42

Relieved with food or antacids

Front 43

time course for gallbladder dz?

Back 43

Prolonged

Front 44

quality, location and circumstances of discomfort for gallbladder dz?

Back 44

Epigastric, right upper quadrant, substernal burning, pressure that may follow meal

Front 45

time course for musculoskeletal dz?

Back 45

variable

Front 46

quality and location for musculoskeletal dz?

Back 46

aching in variable location

Front 47

ass signs and symptoms of musculoskeletal dz?

Back 47

Aggravated by movement

May be reproduced by localized pressure on examination

Front 48

ass signs and symp of herpes zoster?

Back 48

Vesicular rash in area of discomfort

Front 49

quality and location of discomfort in herpes zoster?

Back 49

Sharp or burning pain in Dermatomal distribution

Front 50

Emotional and psychiatric conditions quality and location of pain, time course, ass signs and symp?

Back 50

Variable; may be fleeting, may be retrosternal, Situational factors may precipitate symptoms

Anxiety or depression often detectable with careful history

Front 51

why does The discomfort of angina radiate to the neck, jaw, teeth, arms, or shoulders?

Back 51

common origin in the posterior horn of the spinal cord of sensory neurons supplying the heart and these areas.

Front 52

what precipitates stable angina pectoris symptoms?

Back 52

develops gradually with exertion, emotional excitement, or after heavy meals, any physiologic or psychological stress that induces tachycardia

Front 53

what leads to relief in min?

Back 53

sublingual nitroglycerin or rest

Front 54

T or F: pain that is fleeting (lasting only a few seconds) is rarely ischemic in origin.

Back 54

True

Front 55

pain that lasts for several hours is likely or unlikely to represent angina?

Back 55

UNLIKELY to represent angina, particularly if the patient's electrocardiogram (ECG) does not show evidence of ischemia.

Front 56

why does tachycardia induce anginal episodes?

Back 56

Most myocardial perfusion occurs during diastole, when there is minimal pressure opposing coronary artery flow from within the left ventricle. Since tachycardia decreases the percentage of the time in which the heart is in diastole, it decreases myocardial perfusion.

Front 57

what effect does sublingual nitroglycerin lead to in unstable angina?

Back 57

sublingual nitroglycerin may lead to transient or no relief

Front 58

what symp can be ass with unstable angina?

Back 58

diaphoresis, dyspnea, nausea, and light-headedness.

Front 59

A transient murmur of mitral regurgitation during myocardial ischemia suggest what?

Back 59

suggests ischemic papillary muscle dysfunction.

Front 60

Severe episodes of ischemia can lead to what dreaded complications?

Back 60

pulmonary congestion and even pulmonary edema.

Front 61

Myocardial ischemia caused by hypertrophic cardiomyopathy or aortic stenosis leads to angina pectoris similar to what?

Back 61

that caused by coronary atherosclerosis

Front 62

what term is used to describe patients with angina-like chest pain and ischemic-appearing ST-segment depression during stress despite normal coronary arteriograms?

Back 62

"cardiac syndrome X"

Front 63

what causes the pain in pericarditis?

Back 63

inflammation of the adjacent parietal pleura, since most of the pericardium is believed to be insensitive to pain.

Front 64

which types of pericarditis cause pain? which don't?

Back 64

infectious pericarditis, which usually involves adjoining pleural surfaces, tends to be associated with pain, while conditions that cause only local inflammation (e.g., myocardial infarction or uremia) and cardiac tamponade tend to result in mild or no chest pain.

Front 65

what worsens pericarditis pain?

Back 65

aggravated by coughing, deep breaths, or changes in position—all of which lead to movements of pleural surfaces, pain is often worse in the supine position

Front 66

what causes aortic dissection?

Back 66

spread of a subintimal hematoma within the wall of the aorta. The hematoma may begin with a tear in the intima of the aorta or with rupture of the vasa vasorum within the aortic media. can occur with trauma to the aorta, including motor vehicle accidents or medical procedures in which catheters or intraaortic balloon pumps damage the intima of the aorta. Nontraumatic aortic dissections are rare in the absence of hypertension and/or conditions associated with deterioration of the elastic or muscular components of the media within the aorta's wall. Cystic medial degeneration is a feature of several inherited connective tissue diseases, including Marfan and Ehlers-Danlos syndromes. About half of all aortic dissections in women under 40 years of age occur during pregnancy.

Front 67

pain of thoracic aortic aneurysm?

Back 67

steady, deep, and sometimes severe.

Front 68

Hematomas that extend proximally and undermine the coronary arteries or aortic valve apparatus during an aortic dissection may lead to what?

Back 68

acute myocardial infarction or acute aortic insufficiency.

Front 69

what causes the pain of a PE?

Back 69

due to distention of the pulmonary artery or infarction of a segment of the lung adjacent to the pleura. Massive pulmonary emboli may lead to substernal pain that is suggestive of acute myocardial infarction. More commonly, smaller emboli lead to focal pulmonary infarctions that cause pain that is lateral and pleuritic.

Front 70

what worsens symptoms of pneumonia?

Back 70

inspiration or coughing.