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123Pleurisy: Pulmonary infection or infarction Pleural effusion : Infection, malignancy, heart failure, liver disease, nephrotic syndrome Pulmonary Embolism: DVT, Surgery, Endocarditis, Sickle cell disease Pneumothorax : COPD/Emphysema, Trauma, Mechanical ventilation, Spontaneous Pneumothorax in tall male 4CAUSES: Pancreatitis: I GET SMASHED (google it) Cholecystitis: Infections, tumours, gallstones most commonCholelihiasis risk factors = 4 Fs: Fair, Fat, Female, Fertile, Forty) Oesophageal disease: Oesophagitis, Oesophageal spasm, MallWreiss tears, Boorhave’s syndrome 5*Allodyniafeel pain as a result of something that wouldn't normally hurt 6The Stanford classification divides aortic dissectioninto two groups, A and B: Group A - includes DeBakey TypesI and II and involves the ascendingaorta and can propagate to theaortic arch and descending aorta; the tear can originate anywhere along this path. Pericarditis: Autoimmune, Infectious, metabolic, Drur lated, PostMI complication (Dressler’s syndrome) Myocarditis: Not technically acute chest pain presentation. Symptoms include signs of heart failure: dyspnea, edema, fatigue. Anaemia can also produce palpitations and chest pain due to lower levels of Hb and oxygen in the blood, leading to the heart overcompensating. Stunned myocardium can occur post-ischemia and results in akinetic muscle tissue for days-weeks post ischemic event. Can monitor via ECHO 78B 9D 10When we talk about ACS we are referring to the last 3 only. 1112Emergency Rule of 5: One spray, wait 5 minutes Second spray, wait 5 minutes Call 999 if pain still not gone after that 13PCI is Percutaneous coronary intervention: you insert a balloon with a stent attached that might secrete a drug and you thread it through the artery, usually the femoral artery up to aorta through the coronary arteries into the blocked area. This is done with angiograms. CABG is coronary artery bypass graft. 14MI and unstable angina can occur alittle more variably. Can be brought on by cold winds, a heavy meal or even lying flat. BEWARE SILENT MI especially in DIABETICS or PostMenopausal Women 1516Positive FH: 1st degree relative suffered MI under 55 yeaosd. NM: Male, or premature menopause FBC: Anemia, Infections U&E: Kidney function, Electrolyte balance (esp. if ptt confused), Blood sugar levels LFT: Liver function, (Esp. Clotting factors) TFT: hyperthyroid can cause palpitations, hypothyroid can decrease Cardiac output and subclinical hypothyroidism has been found to lead to worse outcomes following ACS event Troponins: rise steadily following event and pea12ato6rs post (depending on assay) When diagnosing MI, use the universal definition of myocardial infarction. This is the detection of rise and/or fall of cardiac biomarkers (preferably troponin) with at least one value above the 99th percentile of the upper reference limit, together with evidence of myocardial ischaemia with at least one of the following: ▯ symptoms of ischaemia 17▯ ECG changes indicative of new ischaemia (new S- changes or new LBBB) ▯ development of pathological Q wave changes in the ECG ▯ imaging evidence of new loss of viable myocardium or new regional wall motion abnormality. 17Don’t forget to justify each one! Just say a short sentence as to what you would be looking for in the results U&E and LFT just say to establish a baseline in case any medications will be given or imaging is needed 18Arterial thrombi are primarily formed by platelets. Venous thrombi not so much and moer to do with fibrin formation and red blood cells. Therefore need antiplatelets and anticoagulants to protect from both. MONA-SH for STEMI: - Morphine or Metoclopramide (antiemetic) - Oxygen (if hypoxic) - Nitrates (either sublingual or IV) - Aspirin (start with loading dose 300mg) - Statins for secondary prevention - Anti-Hypertensives for secondary prevention - B-Blocker (if no contraindications. *Contraindications = hypotension, bradycardia, CKD) - Coronary Angiography important for those patients with NSTEMI who appear eligible for revascularization. Can show remediable occluded vessel. 19- Rivaroxaban (DOAC) also licensed to be used wtith aspirin and clopidogrel for the prevention of further atherothrombotic events - Dual Anti-platelet therapyis recommended for a minimum of 6 months in patients with stable angina receiving a drug-eluting stent and for 12 months in patients with ACS 1920QRISK2: https://qrisk.org/2017/ HAS-BLED Score for Major Bleeding Risk on patients on anticoagulation 21Dresslers Syndrome (pericarditis) = pericardial inflammation due to immune response +3 weeks post usually. - Fever + Pleuritic Chest Pain - Pericardial friction rub on examination (*separate from pleural friction rub by auscultating while patient holds inspiration) - Ventricular Aneurysm4-6 weeks post 2223Cardioprotective diet 1.2.1 Advise people at high risk of or with CVD to eat a diet in which total fat intake is 30% or less of total energy intake, saturated fats are 7% or less of total energy intake, intake of dietary cholesterol is less than 300mg/day and where possible saturated fats are replaced by mon-unsaturated and polyunsaturated fats. Further information and advice can be found on theNHS Eat well web page. [new 2014] 1.2.2 Advise people at high risk of or with CVD to: reduce their saturated fat intake. increase their mono-unsaturated fat intake with olive oil, rapeseed oil or spreads based on these oils and to use them in food preparation. Further information and advice on healthy cooking methods can be found on theNHS Eat well web page [new 2014] Physical activity 1.2.7 Advise people at high risk of or with CVD to do the following every week: 24at least 150 minutes of moderate intensity aerobic activityr 75 minutes of vigorous intensity aerobic activity or a mix of moderate and vigorous aerobic activity in line with national guidance for the general population (see theNHS Physical activity guidelines for adults). [2008, amended 2014] 1.2.8 Advise people to do muscle-strengthening activities on 2 or more days a week that work all major muscle groups (legs, hips, back, abdomen, chest, shoulders and arms) in line with national guidance for the general population (see theNHS Physical activity guidelines for adults). [new 2014] 1.2.9 Encourage people who are unable to perform moderate-intensity physical activity because of comorbidity, medical conditions or personal circumstances to exercise at their maximum safe capacity[2008, amended 2014] Smoking VBA – very brief advice NRT – nicotine replacement therapy Varenicline partial agonist- blocks the ability of nicotine to activate and stimulate receptors in the mesolimbic dopamine system (this system underlies reinforcement and reward experienced upon smoking). Bupropion– mechanism not well understood but provides anti-craving and anti- withdrawal effects Alcohol AA 24https://www.nhs.uk/conditions/statins/considerations/ Exclude possible common secondary causes of dyslipidaemia (such as excess alcohol, uncontrolled diabetes, hypothyroidism, liver disease and nephrotic syndrome) before referring for specialist review. Must plan annual medications reviews for anyone taking statins. NICE GUIDELINES Before offering a statin, ask the person if they have had persistent generalised unexplained muscle pain, whether associated or not with previous lipidlowering therapy. If they have, measure creatine kinase levels. If creatine kinase levels are more than 5 times the upper limit of normal, re-measure creatine kinase after 7 days. If creatine kinase levels are still 5 times the upper limit of normal, do not start statin treatment. If creatine kinase levels are raised but less than 5 times the upper limit of normal, start statin treatment at a lower dose 25Measure baseline liver transaminase enzymes (alanine aminotransferase or aspartate aminotransferase) before starting a statin. Measure liver transaminase within 3 months of starting treatment and at 12 months, but not again unless clinically indicated Statins are contraindicated in pregnancy: Advise women of childbearing potential of the potential teratogenic risk of statins and to stop taking them if pregnancy is a possibility. Advise women planning pregnancy to stop taking statins 3 months before they attempt to conceive and to not restart them until breastfeeding is finished. 252610 electrodes required for the 12-lead ECG. 6 on precordium and also one on all 4 limbs. 272829Take initial Troponin T or I on initial assessment then1agho inrs 0fter. 50% increase in Troponins is diagnostic Initial Mgx: - Notify senior - Give aspirin - Assess for Coronary reperfusion therapy 3031Block in RBB or LBB will mean that RV or LV will require the other ventricular tissue to depolarise itself first and then spread to the oppsite side. This widens the QRS complex and leads to structural changes as the polarization sequence is different. It will usually cause left or right axis deviation. 1. Wide QRS complex 2. Structural QRS changes 3. Secondary ST-segment changes. (Depression) LBBB always pathological and often a feature of ischemia and structural heart disease RBBB can be physiological and benign. New RBBB in someone with chest pain can point to LAD occlusion The Left Bundle branch actuallysplits further down into an Anterior and Posterior fascicle that both innervate the ant./posA.spects of the LV. If one of them is affected, we get what is called aFascicular Block. Bi-fascicular block is a term that is often mentioned and it means that there is damage to one of the LV fascicles + a 32RBBB occuring together. 32LBBB because V1 has a W shape caused by a deep S wave V6 has a high positive R wave (M shape) 3334AP/PA- when patients are asked to do a PA Xray they have to hug the backboard so that the scapulae can move away from the lungs and we get a clearer picture. If you can see the scapula it means its an AP. Airway- Is the trachea central? Anything in it? Breathing- Do the lung markings reach the edge of the thorax? Any effusions? Pneumothorax? Collapse? Mesothelioma? Asbestosis? Circulation- Any cardiomegaly? Is the heart <50% of the thorax? Aortic Knuckle present? Dilation of great vessels? Dextrocardia? Diaphragm- Are the costophrenic angles clear? Is the hemidiaphragm curved or flattened? Pneumoperitoneum? (EMERGENCY!) Everything Else Any ECG wires? NG tubes? Ventilation Tubes? Chest Drains? Broken ribs/bones? Dislocated shoulder? 35Opacification Vs Consolidation Consolidation is an opacification where the known cause is infective (so you know its pneumonia not an effusion or cancer) 36The “U” shape is called a meniscus sign and it is present for pleural effusions. It differentiates between things like pneumonia and a pleural effusion because pleural effusions are caused by fluid that moves when the patient moves so when the patient stands up it causes a meniscus sign similar to the meniscus of water you see in a lab test tube. Things to find: Right sided pleural effusion ECG lead in image A Tracheal deviation to the right side in image B Also because this is a single sided pleural effusion it is less likely to be heart failure because that usually presents bilaterally. 3738