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Type of Breathing- Slow, Rapid, Deep, Shal
Primary survey check pulse; type of pulse- slow, rapid, weak, strong check breathing; type of breathing- slow, rapid, deep, shallow maintain open airway; clear blood vomitus check to see that airway is unobstructed help the athlete find the most comfortable posistion for breathing be prepared to prefrom artificial ventilation and CPR if needed transport to emergency facility Secondary seurvey history what happend? What is the mechanism of injury? When did it happen? Have you ever had any injury to this region before? Have you ever been ill or had a recent episode of mononucleosis? Was there a direct blow? If so by what? Where were you hit? Back, chest, or abdominal area? How large was the area of contact? Did you go to the bathroom prior to practice? Where does it hurt? Point to the area of pain how severe is the pain? What kind of do you have? Sharp, dull, achy, throbbing, radiating what increase the pain? What relieves the pain? Have the symptoms been constant or intermittent? Does the pain increase during respiration or movement? Is the pain located in the chest wall or does it feel deeper or inside the cavity? Do you have any referred pain to your shoulders? Kehr’s sign? Do you have any refferred pain to your flanks? Did you feel anything at the time of injury? Did you hear any sounds at the time of injury? Do you have any crepitation? Possible rib fx or costochondral separation do you feel any tightness, cramping, or rigidity of the abdominal musculature? Do you feel nauseaqted? Do you have any difficulty breathing? Have you urinated -
Evaluation of Abdominal Pain in the Emergency Department Hartmut Gross, M.D., FACEP
Evaluation of Abdominal Pain in the Emergency Department Hartmut Gross, M.D., FACEP Abdominal pain complaints comprise about 5% of all Emergency Department visits. The etiology of the pain may be any of a large number of processes. Many of these causes will be benign and self-limited, while others are medical urgencies or even surgical emergencies. As with any complaint in the ED, the worst diagnosis is always entertained first. Therefore, there is one thought, which the ED practitioner must maintain in the foreground of his mind: “Is there a life threatening process?” Etiology A breakdown of the most common diagnoses of abdominal pain presentations is listed below. Note that nearly half of the time, “unknown origin” is the diagnosis made. This is a perfectly acceptable conclusion, after a proper work-up has ruled out any life threatening illness. Common Diagnoses of Non-traumatic Abdominal Pain in the ED 1 Abdominal pain of unknown origin 41.3% 2 Gastroenteritis 6.9% 3 Pelvic Inflammatory Disease 6.7% 4 Urinary Tract Infection 5.2% 5 Ureteral Stone 4.3% 6 Appendicitis 4.3% 7 Acute Cholecystitis 2.5% 8 Intestinal Obstruction 2.5% 9 Constipation 2.3% 10 Duodenal Ulcer 2.0% 11 Dysmenorrhea 1.8% 12 Simple Pregnancy 1.8% 13 Pyelonephritis 1.7% 14 Gastritis 1.4% 15 Other 12.8% From Brewer, RJ., et al, Am J Surg 131: 219, 1976. Two important factors modify the differential diagnosis in patients who present with abdominal pain: sex and age. Other common diagnoses of abdominal pain in men and women are as follows. -
Pain Pathways in Orthopaedic Practice J
Postgrad Med J: first published as 10.1136/pgmj.38.437.157 on 1 March 1962. Downloaded from POSTGRAD. MED. J. (I962), 38, I57 PAIN PATHWAYS IN ORTHOPAEDIC PRACTICE J. D. G. TROUP, M.R.C.S., L.R.C.P.* Aberdeen DESPITE Steindler's (1959) admirable lectures on of which time is one of the most significant, have the subject, pain in orthopiedic practice remains a to obtain before pain can be appreciated in tissues difficult problem. To some extent the difficulty is remote from a primary lesion, and when the pain is exaggerated by the adoption of diagnoses based on present, so too are palpably pathological changes. pathological processes which are insusceptible of It is probably true that a peripheral pathway for proof-diagnoses for which it is impossible to pain can be excited centrally or by any stimulus establish an association between symptoms and proximal to it, but the pathway cannot be estab- their alleged origin, let alone a direct causal link. lished in the first place without initial pathological For instance a nipped zygapophyseal synovial changes in the periphery. fringe may well cause acute symptoms, but as there is no means of examining the synovia of The Appreciation of Pain zygapophyseal joints, to make this the diagnosis The appreciation of pain is divided into two is purely speculative. Nevertheless pathological parts; first the sensory component-where it is and guesswork of this sort is regrettably common, and what it feels like, and secondly the affective when some of the latest advances in neuro- component which dictates to what extent the pain by copyright. -
Costochondritis
Department of Rehabilitation Services Physical Therapy Standard of Care: Costochondritis Case Type / Diagnosis: Costochondritis ICD-9: 756.3 (rib-sternum anomaly) 727.2 (unspecified disorder of synovium) Costochondritis (CC) is a benign inflammatory condition of the costochondral or costosternal joints that causes localized pain. 1 The onset is insidious, though patient may note particular activity that exacerbates it. The etiology is not clear, but it is most likely related to repetitive trauma. Symptoms include intermittent pain at costosternal joints and tenderness to palpation. It most frequently occurs unilaterally at ribs 2-5, but can occur at other levels as well. Symptoms can be exacerbated by trunk movement and deep breathing, but will decrease with quiet breathing and rest. 2 CC usually responds to conservative treatment, including non-steroidal anti-inflammatory medication. A review of the relevant anatomy may be helpful in understanding the pathology. The chest wall is made up of the ribs, which connect the vertebrae posteriorly with the sternum anteriorly. Posteriorly, the twelve ribs articulate with the spine through both the costovertebral and costotransverse joints forming the most hypomobile region of the spine. Anteriorly, ribs 1-7 articulate with the costocartilages at the costochondral joints, which are synchondroses without ligamentous support. The costocartilage then attaches directly to the sternum as the costosternal joints, which are synovial joints having a capsule and ligamentous support. Ribs 8-10 attach to the sternum via the cartilage at the rib above, while ribs 11 and 12 are floating ribs, without an anterior articulation. 3 There are many causes of musculo-skeletal chest pain arising from the ribs and their articulations, including rib trauma, slipping rib syndrome, costovertebral arthritis and Tietze’s syndrome. -
1. Intermittent Chest Pain: Angina: • Stable: (Caused By
CVS: 1. Intermittent chest pain: Angina: • Stable: (caused by chronic narrowing in one or more coronary arteries), episodes of pain are precipitated by exertion and may occur more readily when walking in cold or windy weather, after a large meal or while carrying a heavy load; the pain is promptly relieved by rest and/or sublingual glyceryl nitrate (GTN) spray, and typically lasts for less than 10 minutes. • unstable angina (caused by a sudden severe narrowing in a coronary artery), there is usually an abrupt onset or worsening of chest pain episodes that may occur on minimal exertion or at rest. • Retrosternal/ Progressive onset/ increase in intensity over 1–2 minutes/ Constricting, heavy/ Sometimes arm(s), neck, epigastrium/ Associated with breathlessness/ Intermittent, with episodes lasting 2–10 minutes/ Triggered by emotion, exertion, especially if cold, windy/ Relieved by rest, nitrates Mild to moderate. • Aggravated by thyroxine or drug-induced anemia, e.g. aspirin or NSAIDs Esophageal: • Retrosternal or epigastric/ Over 1–2 minutes; can be sudden (spasm)/ C: Gripping, tight or burning/ R: Often to back, sometimes to arms/ A: Heartburn, acid reflux/ T: Intermittent, often at night-time; variable duration/ Lying flat/some foods may trigger/ Not relieved by rest; nitrates sometimes relieve/ Usually mild but esophageal spasm can mimic myocardial infarction. 2. Acute chest pain: MI: • SOCRATES: Retrosternal/ Rapid over a few minutes/ Constricting, heavy/ Often to arm(s), neck, jaw, sometimes epigastrium/ Sweating, nausea, vomiting, breathlessness, feeling of impending death (angor animi)/ Acute presentation; prolonged duration/ ’Stress’ and exercise rare triggers, usually spontaneous/ Not relieved by rest or nitrates/ Usually severe. -
Pseudoanginal Chest Pain Associated with Vagal Nerve Stimulation: a Case Report James B
Nichols et al. BMC Neurology (2020) 20:144 https://doi.org/10.1186/s12883-020-01693-5 CASE REPORT Open Access Pseudoanginal chest pain associated with vagal nerve stimulation: a case report James B. Nichols1, Abigail P. McCallum1, Nicolas K. Khattar1, George Z. Wei1, Rakesh Gopinathannair2, Haring J. W. Nauta1 and Joseph S. Neimat1* Abstract Background: Vagal nerve stimulation (VNS) can be an effective therapy for patients with epilepsy refractory to anti- epileptic drugs or intracranial surgery. While generally well tolerated, it has been associated with laryngospasm, hoarseness, coughing, dyspnea, throat and atypical chest pain, cardiac symptoms such as bradycardia and occasionally asystole. We report on a patient receiving vagal nerve stimulation who experienced severe typical anginal chest pain during VNS firing without any evidence of cardiac ischemia or dysfunction. Thus, the pain appeared to be neuropathic from the stimulation itself rather than nociceptive secondary to an effect on heart function. Case presentation: A 29-year-old man, with a history of intractable frontal lobe epilepsy refractory to seven anti- epileptic medications and subsequent intracranial surgery, underwent VNS implantation without complications. On beginning stimulation, he began to have intermittent chest pain that corresponded temporally to his intermittent VNS firing. The description of his pain was pathognomonic of ischemic cardiac chest pain. On initial evaluation, he displayed Levine’s sign and reported crushing substernal chest pain radiating to the left arm, as well as shortness of breath walking upstairs that improved with rest. He underwent an extensive cardiac workup, including 12-lead ECG, cardiac stress test, echocardiogram, 12-day ambulatory cardiac monitoring, and continuous ECG monitoring each with and without stimulation of his device. -
Surgical Treatment of Angina Pectoris He Extensive
SURGICAL TREATMENT OF ANGINA PECTORIS INGA LINDGREN, M.D., AND HERBERT OLIVECRONA, M.D. Neurosurgical Clinic, Serafimerlasarettet, (Director: Professor H. Olivecrona) and IVth Medical Service, St. Erik's Hospital (Director: Professor H. Berglund), Stockholm, Sweden (Received for publication October ~3, 1946) HE EXTENSIVE researches of Blumgart I have shown that the structural basis for coronary pain is an arteriosclerotic process with obstruction T or obliteration of one or more coronary arteries before an adequate collateral circulation has been developed. On the other hand, if the develop- ment of the collateral circulation has kept pace with the progressive arterial narrowing, myocardial damage and pain are absent even if one or more of the coronary arteries are obstructed. If the increased blood supply to the myocardium demanded by muscu- lar exercise cannot be delivered through the ordinary or collateral channels, coronary pain results. A short rest is usually sufficient to restore the circula- tory balance and the pain subsides. Dilatation of the coronary arteries by nitroglycerine hastens the process and may, if the drug is taken before muscular exertion, prevent an anticipated attack. Vasoconstriction, on the other hand, is an important factor in anginal pain. Practically every sufferer from angina pectoris is worse in the winter; his capacity for muscular work is much less in cold weather. Sudden cooling from any cause is frequently sufficient to bring on an attack. Freedberg, 7 in a series of experiments, has been able to show the effect of cooling upon the exercise tolerance in angina pectoris. He found by testing the same patient's capacity for exercise at different temperatures that the tolerance was much less at temperatures of 7-13~ (45-55~ than at ~4~ (75~ His in- vestigations thus lend experimental support to clinical experience that cold weather has a bad effect on sufferers from angina pectoris. -
Abdominal Pain
10 Abdominal Pain Adrian Miranda Acute abdominal pain is usually a self-limiting, benign condition that irritation, and lateralizes to one of four quadrants. Because of the is commonly caused by gastroenteritis, constipation, or a viral illness. relative localization of the noxious stimulation to the underlying The challenge is to identify children who require immediate evaluation peritoneum and the more anatomically specific and unilateral inner- for potentially life-threatening conditions. Chronic abdominal pain is vation (peripheral-nonautonomic nerves) of the peritoneum, it is also a common complaint in pediatric practices, as it comprises 2-4% usually easier to identify the precise anatomic location that is produc- of pediatric visits. At least 20% of children seek attention for chronic ing parietal pain (Fig. 10.2). abdominal pain by the age of 15 years. Up to 28% of children complain of abdominal pain at least once per week and only 2% seek medical ACUTE ABDOMINAL PAIN attention. The primary care physician, pediatrician, emergency physi- cian, and surgeon must be able to distinguish serious and potentially The clinician evaluating the child with abdominal pain of acute onset life-threatening diseases from more benign problems (Table 10.1). must decide quickly whether the child has a “surgical abdomen” (a Abdominal pain may be a single acute event (Tables 10.2 and 10.3), a serious medical problem necessitating treatment and admission to the recurring acute problem (as in abdominal migraine), or a chronic hospital) or a process that can be managed on an outpatient basis. problem (Table 10.4). The differential diagnosis is lengthy, differs from Even though surgical diagnoses are fewer than 10% of all causes of that in adults, and varies by age group. -
CARDIOLOGY Section Editors: Dr
2 CARDIOLOGY Section Editors: Dr. Mustafa Toma and Dr. Jason Andrade Aortic Dissection DIFFERENTIAL DIAGNOSIS PATHOPHYSIOLOGY (CONT’D) CARDIAC DEBAKEY—I ¼ ascending and at least aortic arch, MYOCARDIAL—myocardial infarction, angina II ¼ ascending only, III ¼ originates in descending VALVULAR—aortic stenosis, aortic regurgitation and extends proximally or distally PERICARDIAL—pericarditis RISK FACTORS VASCULAR—aortic dissection COMMON—hypertension, age, male RESPIRATORY VASCULITIS—Takayasu arteritis, giant cell arteritis, PARENCHYMAL—pneumonia, cancer rheumatoid arthritis, syphilitic aortitis PLEURAL—pneumothorax, pneumomediasti- COLLAGEN DISORDERS—Marfan syndrome, Ehlers– num, pleural effusion, pleuritis Danlos syndrome, cystic medial necrosis VASCULAR—pulmonary embolism, pulmonary VALVULAR—bicuspid aortic valve, aortic coarcta- hypertension tion, Turner syndrome, aortic valve replacement GI—esophagitis, esophageal cancer, GERD, peptic OTHERS—cocaine, trauma ulcer disease, Boerhaave’s, cholecystitis, pancreatitis CLINICAL FEATURES OTHERS—musculoskeletal, shingles, anxiety RATIONAL CLINICAL EXAMINATION SERIES: DOES THIS PATIENT HAVE AN ACUTE THORACIC PATHOPHYSIOLOGY AORTIC DISSECTION? ANATOMY—layers of aorta include intima, media, LR+ LRÀ and adventitia. Majority of tears found in ascending History aorta right lateral wall where the greatest shear force Hypertension 1.6 0.5 upon the artery wall is produced Sudden chest pain 1.6 0.3 AORTIC TEAR AND EXTENSION—aortic tear may Tearing or ripping pain 1.2–10.8 0.4–0.99 produce -
Pain in the Arm: a Symptom Ofheart Disease
410 Postgrad Med J: first published as 10.1136/pgmj.35.405.410 on 1 July 1959. Downloaded from PAIN IN THE ARM: A SYMPTOM OF HEART DISEASE By WALTER SOMERVILLE, M.D., F.R.C.P. Assistant Physician, Department of Cardiology, The Middlesex Hospital Pain in the arm was mentioned in Heberden's heat lamp for his shoulder pain. A chauffeur may first description of angina pectoris, '. sometimes blame his forearm pain on heavy steering. Alert there is joined (with the chest pain) a pain about questioning in these cases may uncover a co- the middle of the left arm . .' (I772). Herrick existing chest sensation and lead to the true cause. (19I2) also referred to arm pain in his first paper Ischaemic pain in the arm is often described by on coronary occlusion, the earliest in the English the patient in similar terms to the typical chest language. When the arm and chest pain of pain. It is said to be cramp-like, squeezing, a band ischaemic heart disease occur at the same time, no around the arm or like ' having my blood pressure diagnostic problem arises. But pain confined to taken.' The arms are often said to ache or feelProtected by copyright. one or both shoulders or arms may be misleading. heavy after a severe attack of angina pectoris. Its real meaning may be missed even in well- The pain is usually felt on the ventral and informed circles. Not long ago, a professor in an medial surfaces of the arm and forearm. It may eminent medical school died suddenly from what extend down to the little finger and the ring was shown at autopsy to be a cardiac infarction. -
Assessing Chest Pain Accurately by Bruce S
Assessing chest pain accurately By Bruce S. Zitkus, EdD, ARNP, CANP, CDE, CFNP ON MONDAY MORNING, John, age 33, accompanied Although heart disease continues to be the leading by his wife, comes into his primary care provider’s offi ce, cause of death in the United States for both men and complaining of chest pain. Two months ago, he had a women, death from cardiac causes has signifi cantly treadmill test for cardiac disease, which was negative. His decreased since 1980 in both sexes.2 To maintain this lab values at the time were normal, except for a positive downward trend in mortality, clinicians must continue Helicobacter pylori blood test. He was started on therapy to diagnose, manage, and treat chest pain appropriately. to eradicate the bacteria; however, he returned this morning with similar chest pain symptoms as he’s had Chest pain evaluation in the past. He denies shortness of breath, palpitations, Understanding the physiology and the relationship be- diaphoresis, or radiation of the pain. He describes the tween pain and its causes is important to differentiate pain as similar to what he’s previously had and stated what may be inducing the patient’s pain.3-5 Pain in the that the medication he’s taking for eradication of the chest region is mostly induced by mechanical, chemical, bacteria in his stomach seemed to be helping; however, or thermal means and is considered to be nociceptive his pain today won’t go away. Although his ECGs in the (see Mechanism of acute pain). Nociceptive pain arises past were negative, his ECG today shows signifi cant from specifi c pain receptors and is classifi ed as somatic ST segment elevations in the inferior leads with corre- or visceral in nature. -
The Dental Connection in Cardiac Pain and Arrhythmia by David L Lerner, DDS, P.C., F.I.N.D., C.Ac
The Dental Connection in Cardiac Pain and Arrhythmia by David L Lerner, DDS, P.C., F.I.N.D., C.Ac. In her work on the study of trigger points, Janet Travel, MD1 spoke of her observations that trigger points in the Pectoralis Major seemed to generate reflexive reaction in the heart resulting in irregular heart beats. Sometimes the pain originating in the tight tender areas of this muscle were perceived by the patient as coming from their heart. Pectoralis Major Muscle and the Cardiac Trigger Point Phenomena A) overlapping referred pain patterns of two parasternal trigger points (x’s), located in the medial sternal section of the muscle B) location of the “cardiac arrhythmia” trigger point (x) below the lower border of the fifth rib in the vertical line that lies midway between the sternal margin and the nipple line. On this line the sixth rib is found at the level of the tip of the xiphoid process (arrow) This vertical line corresponds to the pathway of the Kidney Meridian and the trigger points are found at K21, 22 Other authors have spoken of the relationships between dysfunction of the Pectoralis Major and associations with cardiac dysfunction Schwartz and Bourassa2 state that in the Coronary Artery Surgery Study Registry of the 1970s, normal angiograms were found in 19% of patients, and suggest that the statistics today are not much different . They raise the question; “ is there a non-cardiac cause of chest pain? ”, and list numerous possible causes including chest pain of musculo-skeletal origin. In an article entitled Cardiac Pain Syndrome3, Andrei Pikalov, MD, PhD writes about three variations of anterior chest wall syndrome (ACWS) that are associated with cervical, thoracic and cervical-and-thoracic pathology.