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Acute Coronary Syndrome (MI)

- Emergency
**Myocardial infarction. Pain lasts >30min,
assoc w dyspnoea, diaphoresis,
hypotension, nausea and vomiting. Classify
as NSTEMI or STEMI**
(+) Substernal/left sided chest pressure or
tightness, gradual onset, pain radiates to
shoulders, with exertion
(+) Orthopnea, paroxysmal noctournal
dyspnea
(+) Elderly, women, diabetics have Atypical"
symptoms (eg, dyspnea, weakness). Elderly
can have dyspnea, weakness, syncope
alone Tightness
- PE: nonspecific, HF, Levines sign (fisted
hand placed over chest)
- Risk: DM, HTN, Hyperlipidemia
- Dx: Troponin I, CK-MB, ECG (ST elevation,
Q waves, new LBBB)

Heart Failure
- Right sided, Left sided, Congestive.
Decreased ability to pump blood. Can
result from heart attack, heart valve
disease or chronic HTN
(+) Exertional dyspnea, displaced apex
beat, limb/pulmonary edema
(+) Valvular heart disease may cause
chest discomfort, which may signify
worsening valvular function

Tachyarrhythmia
- Causing O2 demand. Paroxysmal
SVT, VT, etc
(+) Palpitations, irregular heartbeat, may
cause shock/syncope. Valsalva/carotid
massage can relieve episode of SVT
- In VT, look for ischemic changes

Sympathetic stimulation
- Pheochromocytoma, thyrotoxicosis,
drug (cocaine, amphetamines)

Pericarditis
(+) Pleuritic chest pain, relieved on sitting
up, worse when supine
- PE: pericardial friction rub, signs of
tamponade (muffled heart sounds,
distended neck veins, hypotension)
- Etiology: infective, neoplastic, uremic,
post-MI, autoimmune

Pleuritis
Aortic Dissection

Pulmonary Embolism

- Emergency
(+) Sudden onset of sharp, tearing, or
ripping pain, Maximal severity at
onset, Most often begins in chest or
back, radiate to the back between the
scapula
- Can mimic: stroke, ACS, mesenteric
ischemia, kidney stone
- Risk: Marfans, Ehler-Danlos
- PE: Absent upper extremity or
carotid pulse, discrepancy in systolic
BP >20 mmHg between R/L upper
extremity (unequal pulse), AR murmur,
neurologic findings (hoarseness,
paraplegia, altered mental status)
- Dx: CXR wide mediastinum or loss
of normal aortic knob contour

- Emergency
(+) Pleuritic pain, painless dyspnea
(main feature), sudden onset,
cardiorespiratory compromise
(hypotension, tachycardia >100,
hypoxia), hemoptysis
- Risk: Immobilization (examine
calves for erythema, swelling,
tenderness), malignancy
- PE: non specific lung exam,
tachypnea, focal wheezing maybe
- Dx: D-dimer testing

Cardiovascular
- New murmurs, S3 & S4 sounds,
elevated JVP. Look for xanthelesma,
arcus senilis (hyperlipidemia),
acanthosis nigricans (DM)

Angina
- Angina: stable coronary artery dx,
substernal with characteristic quality
and duration, triggered by effort or
emotion, and completely relieved by
rest or GTN
- Unstable angina: due to plaque
rupture, worsening coronary
occlusion without myocardial death.
Pain occurs with minimal effort or
even at rest and is incompletely
relieved by GTN. Increased
frequency, crescendo severity, new
oset
- Variant Angina: due to vasospasm

Myocarditis
- Features of viral infection
(+) Otherwise healthy pts who would
have no reason for new cardiac
symptoms (e.g. young guys), or if
tachycardia is disproportionate to
fever (usual 10 beats/min per
1C)
(+) Symptoms arise fr myocardial
inflammation (chest pain, arrhythmia)
and from cardiac function (acute
heart failure, sudden death). Viral
sym (fever, malaise, arthralgia) are
common

Respiratory
- Consolidation, crepitations (cardio vs
respi causes), ronchi, hyperresonance,
effusion, and tracheal shift (tension
pneumothorax). LN, ptosis, and
clubbing

Acute Chest Pain


78 year old female with
crushing central chest pain
for 20 minutes
Gastrointestinal

Other
MSK: Costochondritis
(Tietze Syndrome),
intercostal muscle strains,
rib contusions and fractures
(+) Pain well localized, worsened by
chest wall motion by breathing,
percussion or coughing, and there is
usually a reproducible localized point
of tenderness (distinguish fr pleuritic
pain)
- Hx of trauma or strenuous activity

Cervical Disk Disease


- Nerve root compression

Herpes Zoster
(+) Dermatomal Pain before rash

Psychosomatic
(+) Hysteria, Depression, Panic attack
(+) Hx of panic attack during fright,
anxious, very uneasy, or no reason
heart race, feel faint, SOB

Tension Pneumothorax
- Emergency
(+) Often sudden onset SOB, Initial
pain often sharp and pleuritic,
Dyspnea dominant
- May be secondary to lung
pathology (e.g. COPD, Marfans),
spontaneous, or traumatic
- PE: Ipsilateral diminished or absent
breath sounds, decreased chest
expansion, hyperresonance,
decreased air entry, tacheal shift

Mediastinitis (Esophageal
rupture)
- Emergency
- Boerhaaves syndrome
(+) Forceful vomiting often precedes
esophageal rupture, recent
endoscopy, odontogenic infection,
coexistent respi/GI symptoms
- Released by antianginal therapy
- PE: Ill appearing (shock, fever),
may hear (Hamman's) crunch over
mediastinum
- Esophageal spasm mimic cardiac
ischemia or aortic dissection

- Viral, autoimmune
(+) Pleuritic sharp chest pain, dry
cough, fever, chilld, rapid shallow
breathing, SOB, tachycardia, sore
throat. Worse with deep breathing or
cough

Pneumonia
(+) Dyspnea and fever, egophony
(increased resonance), dullness to
percussion, tachypnea, sputum,
night sweats, myalgia. No sore
throat, no rhinorrhea

Lung Cancer
(+) hemoptysis, weight loss, SOB,
chest pains, hx of smoking, systemic
symptoms (clubbing)

Asthma/COPD
(+) Chest tightness, dyspnoea,
coarse lung crepitations, wheeze
(COPD)
- Increased pulmonary arterial
pressures and resultant right sided
heart dysfunction (cor pulmonale)

Gastroesophageal Reflux Disease


(+) Deep burning epigastric discomfort and
sometimes a sour taste in the throat,
retrosternal burning, exacerbated by lying
down, food, alcohol, and aspirin, but
relieved by antacids
** Note that vomiting can occur in MI and
does not always point to a GIT etiology

Referred pain from


Subdiaphragmatic Pathology
(+) Abdominal masses, acute
abdomen pain, jaundice
(+) Epigastric discomfort, retrosternal
burning
- No acute coronary syndrome
- Peptic ulcer disease, biliary disease,
pancreatitis, subphrenic abscess