General Principles of DiagnosisLabs to ID chest painClassic stable anginaUnstable anginaVariant or mixed anginaCoronary ischemia- labstesting used to detect coronary ischemiaPericarditis- HistoryPericarditis- PhysicalPulmonary embolismMusculoskeletal PainPleurisyHow to interpret an EKGArrhythmias - 4 quick questionsSinus tachycardia – criteria, HR > 100 bpmSinus bradycardia - criteriaHR< 60 bpmST segment elevation - reasonsstress test - pt preparationstress test - pt preparationStress test - finished when?ST segment depressionSinus arrhythmia:Appearance is ALMOST NORMAL: Respiratory - Circulatory interaction Rate INCREASES with INSPIRATION (IN=IN)PSVT (Paroxysmal Supraventricular Tachycardia) AKA: AV nodal Re-entrant TachycardiaAtrial flutterAtrial fibrillationPAT(Paroxysmal (episodic) Atrial Tachycardia)PVCs (Premature Ventricular Contractions)Reasons to worry about PVCs?PVC - R on T: A PVC falls on the T wave of the second sinus beat, initiating a run of ventricular tachycardia.Multiple PVC foci: Beats 1 and 4 are sinus in origin. The other three beats are PVCs. The PVCs differ from each other in shape (multiform), and two occur in a rowVentricular tachycardiaVentricular FibrillationAccelerated Idioventricular RhythmTorsades de Pointes1º AV block2º AV Block - Wenckebach or Mobitz Type I2º AV Block - Mobitz Type II3º AV BlockBundle branch blocks - general criteriaRight bundle branch block (RBBB)Left bundle branch block (LBBB): LV depolarization is delayed. Criteria: Wide QRS > 0.12 Broad (+/- notched) R waves, ST depression & T-wave inversion in I, aVL, V5, V6 Broad S waves in V1, V2 Left axis deviation may be presentMI evolution: three phasesIschemic signsNSTEMINURS 8026 1st EditionExam # 2 Study Guide Lectures: 4 - 7Lecture 4(February-3)Abdominal PainImportance of demographics of abdominal pain:1. ETOH at risk for pancreatitis 2. Sickle cell predisposing factor for acute abdomen in AA3. S/p abdominal surgery increases risk of obstruction4. Duodenal ulcers rare before age 15, appendicitis is not Intestinal obstruction d/t malignance is more often in patients>40 5. Bowel ischemia is more prevalent in the elderly6. Pelvic pain in the 75yo think diverticulitis/carcinoma pelvic pain in 25yo think PID, ectopic, ruptured cyst Abdominal pain in childrenFlu/gastroenteritis Food poisoning/food allergies Poisoning AppendicitisDifferential w/childrenDuration >24 hours, location, appearance, duration & type of emesis, diarrhea that persists beyond 3 days or is bloody, groin pain, urination problemsAbdominal Pain Pathophysiology: Pain impulses originate w/in the abdominal cavity Transmitted via the autonomic & anterior/ lateral spinothalamic tracts. 3 major causes of pain Colic (spasm) Ischemia (loss of flow) Peritoneal inflammationAnatomy of PainRight Upper Quadrant:Cholecystitis, biliary colic, hepatitis, hepatic abcess, hepatomegaly secondary to CHF, right lower lobe pneumonia, colitisEpigastric: Aortic aneurysm, MI, pancreatitis, PUD, early appendicitis, gastritisLeft Upper Quadrant: Gastritis, pancreatitis, splenomegaly, left lower lobe pneumonia, splenic rupture or infarct Right or Left Flank: Nephrolithiasis, pylonephritisRight Lower Quadrant: Appendicitis, ectopic, salpingitis, testicular torsion, mittleschmertz, ovarian torsion/cyst, inguinal hernias, Psoas abcess, and ureteral calculiUmbilical: AAA, early appendicitis, bowel obstruction, gastroenteritis, IBD, mesenteric ischemia/infarct enteritis, umbilical hernia Left Lower Quadrant: Colon ca, diverticulitis, ectopic, salpingitis, IBD, mittleschmertz, ovarian torsion/cyst, testicular torsion, inguinal hernias, Psoas abscesses, ureteral calculiHypogastric: Cystitis, endometriosisDiffuse: Hemolytic crisis (sickle cell), gastroenteritis, peritonitis, endocrine disorders (DKA, Addison’s, HPT), intestinal obstructionHistory: Women: Regardless of age inquire about? Vaginal bleeding – LMP Sexual history Obstetric history Ectopic risk factors: PID, IUD, previous ectopic, tubal surgery (or ligation), infertility, h/o endometriosis,History for Man Men: HesitancyNocturia Low urinary volume/lower abd distention Sexual historyHistory: PMH- Previous abd surgery, CV disease Analgesic use (acute & chronic)- ETOH/tobacco/substance abuse - Weight change, bowel habit change- Chronic illness - Risk factors- Recent travel Environmental exposures - Allergies - H/o domestic violenceRed Flags for Abdominal Pain (Adults): 1. Pain that changes location2. Pain that awakens from sleep3. Weight loss4. Pain that persists for >6 hours or worsens 5. Pain followed by vomitingRed Flags for Abdominal Pain (Childerns): 1. Pain location distant from umbilicus2. Pain that awakens from sleep 3. Weight loss or deceleration of weight gain 4. Elevated sed rate 5. Projectile vomiting6. Current jelly stool 7. Bulky foul-smelling clay colored stoolsHistory1. FH Appendicitis = increased risk2. Medication history Anticoagulant – development of abd hematomas3. OC – hepatic adenomas w/mesenteric infarction 4. Steroids – mask the symptoms of peritonitisHistory of PI1. Location Onset- what were they doing when it started? 2. Radiation 3. Duration: how long has it lasted? >6 hours maybe a surgical abdomen 4. Aggravating factors (movement, coughing) 5. Relieving factors (position, vomiting, meds) 6. Mode of onset? W/progression: Better, same, worse, abruptness7. Previous similar episodes Infant may become fussy, draw his or her legs up toward the belly, and eat poorlyAcute Abdominal Pain: Timing Abrupt onset -instant GI Causes: 1. Perforated ulcer2. Ruptured abscess/ hematoma3. Intestinal infarct 4. Ruptured esophagusAcute Abdominal Pain: Timing Abrupt onset –Non- GI Causes: 1. Ruptures/dissecting aneurysm2. Ruptures ectopic 3. Pneumothorax 4. MI5. Pulmonary infarct Acute Abdominal Pain Timing Rapid-onset minutes-GI-Causes1. Perforated viscus 2. Strangulated viscus 3. Volvulus 4. Pancreatitis5. Biliary colic6. Mesenteric infarct7. Diverticulitis8. Penetrating peptic ulcer9. High intestinal obstructionAcute Abdominal Pain Timing Rapid-onset minutes-NON-GI-Causes1. Ureteral colic 2. Renal colic3. EctopicAcute Abdominal Pain Timing Gradual onset – hours-GI-causes1. Appendicitis 2. Strangulated hernia 3. Low intestinal obstruction4. Cholecystitis5. Pancreatitis 6. Gastritis7. Peptic ulcer8. Crohn’s disease9. Ulcerative colitisAcute Abdominal Pain Timing Gradual onset – hours-NON-GI-causes1. Cystitis2. Pyelonephritis3. Prostatitis4. Salpingitis5. Threatened