chest pain Flashcards
Chest Pain * Diseases of :
a) H e a r t
b) A o r t a
c) lungs pleura
d) mediastinum
e) oesophagus
f) stomach
g) abdominal viscera
h) musculoskeletal
i) psychological
differential Dx of chest pain
-aortic dissection
-acute coronary syndrome
_pulmonary embolism
-pneumothorax
-mediastinitis
-pericardial tamponade
- A 58 year old male * Smoker * Systemic Hypertension * Dyslipidemia * Diabetes mellitus type 2 * L e f t sided chest pain since last 30 minutes * Squeezing pain
gradual onset
radiating to jaw and l e f t arm
associated with dyspnea, sweating and
vomiting
On ex : Pul : 90/min BP : 150 I90 mm Hg RR :20/min
-onset is gradual
_pain increasing on exertion
-dyspnea
Acute Coronary Syndrome
clinical examination of acute coronary syndrome
- Signs ofHeartfailure;
Acute LVF
Bradycardia / He a rt block /
Hypotension
investigation of acute coronary syndrome
-ECG
-cardiac enzyme
-2D echocardiogram
Acute Coronary Syndrome
Acute coronary syndrome refers to any
constellation of clinical symptoms t h a t are
compatible with acute myocardial ischemia and
encompasses acute myocardial infarction.
- STEMI, - NSTEMI, - Unstable Angina
Cardiac Enzymes
-Troponin I & Troponin T
-CK-MB 95%
Management
of
acute coronary syndrome
- Oxygen Inhalation
- Morphine - pain relief
- Antiplatelets
- Statins
- Betablockers
- ACEI/ARB
- IV/ SC Heparin / Thrombolysis / PCI
- +/- Diuretics
which type of MI we can not use morphin?
inf MI cuz we see bradycardia and hypotension
- 70 year old male
- Systemic Hypertension
- Sudden onset Chest pain tearing in nature along the back
- Sudden onset of sharp, tearing or ripping
pain - Maximal severity at onset
- O f t e n begins in chest / can begin in back
- ECG : Ischemic changes
30 % - Non specific ST -T changes - CXR : Wide mediastinum /
Loss of Normal Aortic Knob Contour - 76 °/o Normal -10 %
aortic dissection
A 50 Year old female Surgery neck of femur Prolonged bed r e s t
swelling of l e f t lower limb since 1 week
sudden onset dyspnea since 4 hrs associated sharp catchy chest pain on r i g h t side
On ex : Tachypnea!!!!
Pulse : 110 /min BP : 110/60 mm Hg Chest: Clear; CVS : S1+S2+
???
Pulmonary Embolism - The Great Masquerader
risk factors
-Prolonged Immoblization
-Deep Vein Thrombosis –Malignancy
clinical examination of Pulmonary Embolism
- Extremity - may be normal
- Tachypnea - common
Tachycardia - Jugular venous distension
- Non specific focal rales * Absent b r e a t h sounds
blood tests for pulmonary embolism
- D-dimer
-Cardiac Biomarkers (elevated troponin)
Pulmonary Embolism
ecg
-T wave inversion in V1-V4
Signs of Right heart strain - Right axis deviation - RBBB - Right a t ria l enlargement
S1Q3T3
is echocardiography for diagnostic value?
no,Useful to rule out mimics of PE :
* Acute MI * Pericardial Tamponade * Aortic Dissection * Mc Connell’s Sign
Specif ic Appearance of RV
Hypokinesia of RV f r e e wall wi t h normal
motion of RV apex
dx for pulmonary embolism
MDCT Chest wi t h Contrast + Pulmonary angiogram**
- A 50 year old male * COPD -Emphysema * Sudden onset Right Chest Pain - Sharp , Catchy * W i t h predominant Dyspnea
- On Ex : Pul 100 i m i n BP : 110/60mmHg RR: 40/min * Deviation of trachea to l e f t side * Hyperresonance - Rt side of chest * Diminished Breath sounds - Right side of chest
Pneumothorax
Clinical Examination of Pneumothorax
- Tachypnea * S h i f t of mediastinum to contralateral side * Ipsilateral diminished or absent breath
sounds
- A 30 year old male * Alcoholic * Post alcohol consumption * Devoleped severe retching and vomitings * Followed by excruciating r e tr o s te r n a l chest pain * Also upper abdominal pain
- On Ex : Tachypnea
Cyanosis Fever Hypotension - Shock
Mediastinitis - Esophageal Rupture
Mediastinitis - Esophageal Rupture
- Occurs in Alcoholics Patients wi t h gastric or duodenal ulcer
- Spontaneous perforation of esophagus a f t e r vomiting
(Boerhaave’s Syndrome)
Cardiac Tamponade
- Sharp anterior chest pain made worse by lying
down - Pain relieved by s i t t i n g f o r wa r d
- Pain aggravated by inspiration
- Dyspnea : common
Clinical examination
of cardiac temponade
- Sinus tachycardia
- Elevated JVP
- Pulsus Paradoxsus
- Hypotension
- M u f f l e d heart sounds
Echocardiography
of cardiac temponade
- Diastolic collapse of r i g h t ventricle and rig h t
atrium - Diastolic collapse of left ventricle - more
specific
pericarditis
- Retrosternal and l e f t precordial pain * Radiate to l e f t shoulder, neck * Aggravated by inspiration , movement, swallowing * More in supine position * Relieved in sitting and leaning forward position
- On ex : Pericardial frictional rub
Widespread concave ST elevation and PR
depression is present throughout the precordial
(V2-6) and limb leads (I, II, aVL, aVF). There is reciprocal ST depression and PR
elevation in aVR.
