Acute Chest Pain DDX
A 52-year-old man presents to the emergency department with sudden onset, substernal chest pain that radiates to his left arm and jaw. He describes the pain as a severe, pressure-like sensation that began 30 minutes ago while he was at rest. He has a history of hypertension and hyperlipidemia, but no prior history of heart disease. On physical examination, he appears diaphoretic and slightly short of breath.
Which of the following is the most appropriate initial test to prioritize for evaluating this patient’s chest pain?
A) Chest X-ray
C) EKG (electrocardiogram)
D) CT angiography of the chest
E) Echocardiogram
EKG to rule out a MI.
The heart sound S3, also known as ventricular gallop, occurs in early diastole (before S1), and is due to ____________________________
The heart sound S3, also known as ventricular gallop, occurs in early diastole (before S1), and is due to increased volume or rapid ventricular filling.
The Baroreceptor Reflex operates through baroreceptors in the _________ (glossopharyngeal nerve) and the ______ (vagus nerve), which synapse in the nucleus tractus solitarius in the medulla to transmit information about blood pressure
The Baroreceptor Reflex operates through baroreceptors in the carotid sinus (glossopharyngeal nerve) and the aortic arch (vagus nerve), which synapse in the nucleus tractus solitarius in the medulla to transmit information about blood pressure
The genetic mutation in Marfan syndrome causes dysfunctional _____
The genetic mutation in Marfan syndrome causes dysfunctional fibrillin.
An Aortic Dissection is a tear of the aortic wall, creating a _______ that can compromise blood flow to vital organs.
An Aortic Dissection is a tear of the aortic wall, creating a false lumen that can compromise blood flow to vital organs.
_________ may cause a chest pain that is uniquely relieved by learning forward
Pericarditis may cause a chest pain that is uniquely relieved by learning forward
_______ is the process in formation of a platelet plug. ________ is the process of forming a fibrin network through the intrinsic and extrinsic pathways.
Primary hemostasis is the process in formation of a platelet plug. Secondary hemostasis is the process of forming a fibrin network through the intrinsic and extrinsic pathways.
The receptors of sympathetic nervous system are _______ receptors, meaning they respond to ________
The receptors of sympathetic nervous system are adrenergic receptors, meaning they respond to epinephrine/norepinephrine.
The most common cause of death in Marfan’s, generally speaking, is ___________
The most common cause of death in Marfan’s, generally speaking, is cardiovascular impairment
What is the difference between a AAA and a TAA?
AAA: Occurs in the abdominal portion of the aorta, typically below the renal arteries.
TAA: Occurs in the thoracic portion of the aorta, above the diaphragm and can involve the ascending aorta, aortic arch, or descending thoracic aorta.
Given five examples of a chest pain ddx
The intrinsic pathway is activated by damage to the ________, whereas the extrinsic pathway is activated by ________.
The intrinsic pathway is activated by damage to the vascular endothelium, whereas the extrinsic pathway is activated by external trauma.
Labetolol was given to Ms. Connelly, what is it’s MOA and why was it given?
Blocks alpha-1 and beta-adrenergic receptors. Was given for blood pressure, works in both the blood vessels and heart. She was switched from atenolol.
Abnormalities in cardiac looping can lead to the abnormal heart defect of _____
Abnormalities in cardiac looping can lead to dextrocardia
Describe the location and compare the risk level/treatment of a Stanford Type A Aortic Dissection vs a Stanford Type B.
Stanford Type A is in an ascending aorta, Stanford Type B is ONLY the descending aorta. Stanford Type A is more of an emergency and surgical intervention is usually required urgently to prevent fatal complications, as untreated Type A dissections have a high mortality rate. Type B is typically managed with medical therapy, primarily blood pressure control, if there are no complications. Surgery or endovascular repair is considered if there are complications like organ ischemia, rupture, or persistent pain.
A patient presents with sudden chest pain and syncope with hemoptysis shortly after a long car trip. This is a classic presentation of which disorder? What imaging is gold standard for diagnoses?
This is a likely PE. So a CT pulmonary angiogram would be the gold standard
The intrinsic pathway has four unique factors: ____
The extrinsic pathway has two unique factors: ____
They meet at factor __ of the common pathway, which also includes factors __ and __.
The intrinsic pathway has four unique factors: 12, 11, 9, and 8
The extrinsic pathway has two unique factors: 3 and 7
They meet at factor 10 of the common pathway, which also includes factors 5 and 2.
Count backwards from 12 to 8 skipping 10 for intrinsic
3 + 7 = 10 for extrinsic
5 x 2 = 10 for common
With X (10) marking the spot where they intersect
Match the receptors with whether they work on IP3 or cAMP, and whether they activate or inhibit
a1,a2,b1,b2,b3
a1 - activates IP3
a2 - inhibits cAMP
b1,2,3 - activates cAMP
The genetic mutation for Marfan’s is _____
The genetic mutation for Marfan’s is FBN15
The average diameter of an adult aorta is ___ mm, it is considered an aneurysm if its diameter is greater than ____. (Depends on the location, ascending aorta is normally larger)
The average diameter of an adult aorta is ~22 mm, it is considered an aneurysm if its diameter is greater than ~40mm. (Depends on the location, ascending aorta is normally larger)
Chest pain radiating to the back classically has three major ddx. Name two.
Aortic Dissection: Often presents as a sudden, severe, “tearing” or “ripping” chest pain that radiates to the back, especially between the shoulder blades. This is a medical emergency and typically accompanied by signs like pulse deficits or blood pressure differences between limbs.
Pancreatitis: Presents as severe, steady epigastric pain that often radiates to the back. It’s usually associated with nausea, vomiting, and may worsen after eating or lying flat. Elevated pancreatic enzymes (amylase and lipase) can aid in diagnosis.
Esophageal Rupture (Boerhaave Syndrome): Characterized by severe chest pain that can radiate to the back and is often precipitated by vomiting or retching. This is also an emergency and may be accompanied by subcutaneous emphysema, mediastinal crunch (Hamman’s sign), or signs of shock.
In the common pathway _____ (with cofactor Va) converts ______ to _______. This _______ then converts ______ to ______, forming a stable clot.
In the common pathway Factor Xa (with cofactor Va) converts prothrombin (II) to thrombin (IIa). Thrombin then converts fibrinogen (I) to fibrin (Ia), forming a stable clot.
For each action, say the receptor:
1. decreases Heart rate, decreases conduction velocity
2. bladder relaxation, increases lipolysis
3. peripheral vasoconstriction, increase preload and afterload, sphincter contraction, mydriasis
decreases Heart rate, decreases conduction velocity M2
bladder relaxation, increases lipolysis b3
peripheral vasoconstriction, increase preload and afterload, sphincter contraction, mydriasis a1
Tetralogy of Fallot is a congenital heart defect with four specific heart programs:
The clinical triad of an Aortic Dissection is: