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Rapid eval for potential Acute Coronary Syndromes (ACS): Important history
- Onset and character of pain
- Prior History of CAD.
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How can troponin be used to rule out MI
Normal serial troponin measurements 10 hours after symptom onset can essentially exclude MI. Normal troponins can inform short term prognosis: only 1 in 300 patients with normal ECG and a normal troponin I level 6 hours after chest pain onset will have an adverse cardiac outcome in the next 30 days.
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How is serum myoglobin helpful in rapidly ruling out MI
when serial measurements remain within normal range and do not double over 2 hours time, within 6 hours of symptom onset. Only about 3% of those in the ED without change in myoglobin will have an MI.
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ECG in pulmonary embolism has, in order of positive predictive value:
- 1. Sinus tachycardia
- 2. S1Q3T3 pattern
- 3. Rightward axis deviation
- 4. Right bundle branch block
- 5. ST depression in rt precordial leads
- 6. p-pulmonale
- 7. ST elevation in lead III.
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Diagonal ear lobe creases are associated with what diagnosis?
CAD
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Reduction or dissappearance of the brachial and carotid pulses is associated with what diagnosis?
- Aortic dissection.
- Also, inequality of blood pressure in both arms of patients with chest pain.
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Exam findings that help rule in vascular disease:
diminished or absent pedal pulses, or audible bruit. Leg complaints, absence of femoral pulse, presence of femoral artery bruit.
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RED FLAG: Mediastinal widening is associated with what diagnosis?
Aortic dissection with severe tearing or ripping pain.
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RED FLAG: Arrhythmia and/or chest pain in younger patient
Is associated with what diagnosis?
cocaine abuse
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RED FLAG: new systolic mitral murmur
is associated with what diagnosis?
ruptured papillary muscle
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RED FLAG: ECG changes, especially ST segment elevation or new left bundle branch block.
Is associated with what diagnosis?
MI
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Red Flag: tachycardia, tachypnea, hypoxia
Is associated with what diagnosis?
pulmonary embolism
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Red Flag: hypotension, poor tissue perfusion, pulmonary edema, or oliguria
is associated with what diagnosis?
decreased cardiac output, possible large anterior MI
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How do panic attacks usually present?
May have substernal chest pressure accompanied by fear of imminent death, choking sensations, shortness of breath, palpitations, sweating, lightheadedness, tremulousness, and/or nausea, paresthesias, fear of "going crazy", derealization (feelings of unreality), and depersonalization (feelings of being outside of or detached from oneself).
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Risk factor points for AMI:
- 1 point for each:
- 1. Age over 60 years
- 2. Male sex
- 3. Pain described as pressure
- 4. Pain radiating to arm, shoulder, neck or jaw
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What EKG changes are seein in pericarditis?
diffuse ST changes involving precordial and limb leads.
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How does pain in pericarditis present?
worse when recumbant, releived by sitting forward.
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A patient with localized sharp or pleuritic chest pain likely has:
Pain from a non-cardiac origin.
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A patient with a profound sense of unease accompanied by nausea and vomiting probably has what type of MI
Inferior
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How do elderly patients with ACS often present
with shortness of breath rather than chest pain.
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How do diabetics with ischemic cardiac pain present?
They may have little or no pain
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Women with ischemic cardiac pain are more likely to report their pain where?
In the neck, back or epigastrium.
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Findings on ECG in a person with ACS in order of importance
- 1. ST segment elevation or depression of > 1mm in at least 2 consecutive leads.
- 2. Q waves in at least 2 leads, not including aVr, not know to be old
- 3. T-wave hyperacuity or inversion in at least 2 leads, not including aVr
- 4. New bundle branch block.
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The 2 most common causes of chest pain in primary care in order:
- 1 musculoskeletal
- 2. Reflux
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