chest pain

Question 1

Chest Pain * Diseases of :

Answer 1

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

Question 2

differential Dx of chest pain

Answer 2

-aortic dissection
-acute coronary syndrome
_pulmonary embolism
-pneumothorax
-mediastinitis
-pericardial tamponade

Question 3

• 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

Answer 3

Acute Coronary Syndrome

Question 4

clinical examination of acute coronary syndrome

Answer 4

• Signs ofHeartfailure;
   Acute LVF
   Bradycardia / He a rt block /
   Hypotension

Question 5

investigation of acute coronary syndrome

Answer 5

-ECG
-cardiac enzyme
-2D echocardiogram

Question 6

Acute Coronary Syndrome

Answer 6

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

Question 7

Cardiac Enzymes

Answer 7

-Troponin I & Troponin T
-CK-MB 95%

Question 8

Management
of
acute coronary syndrome

Answer 8

• Oxygen Inhalation
• Morphine - pain relief
• Antiplatelets
• Statins
• Betablockers
• ACEI/ARB
• IV/ SC Heparin / Thrombolysis / PCI
• +/- Diuretics

Question 9

which type of MI we can not use morphin?

Answer 9

inf MI cuz we see bradycardia and hypotension

Question 10

• 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 %

Answer 10

aortic dissection

Question 11

 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+

Answer 11

???

Question 12

Pulmonary Embolism - The Great Masquerader
risk factors

Answer 12

-Prolonged Immoblization
-Deep Vein Thrombosis –Malignancy

Question 13

clinical examination of Pulmonary Embolism

Answer 13

• Extremity - may be normal
• Tachypnea - common
  Tachycardia
• Jugular venous distension
• Non specific focal rales * Absent b r e a t h sounds

Question 14

blood tests for pulmonary embolism

Answer 14

• D-dimer
  -Cardiac Biomarkers (elevated troponin)

Question 15

Pulmonary Embolism
ecg

Answer 15

-T wave inversion in V1-V4
Signs of Right heart strain - Right axis deviation - RBBB - Right a t ria l enlargement
S1Q3T3

Question 16

is echocardiography for diagnostic value?

Answer 16

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

Question 17

dx for pulmonary embolism

Answer 17

MDCT Chest wi t h Contrast + Pulmonary angiogram**

Question 18

• 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

Answer 18

Pneumothorax

Question 19

Clinical Examination of Pneumothorax

Answer 19

• Tachypnea * S h i f t of mediastinum to contralateral side * Ipsilateral diminished or absent breath
  sounds

Question 20

• 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

Answer 20

Mediastinitis - Esophageal Rupture

Question 21

Mediastinitis - Esophageal Rupture

Answer 21

• Occurs in Alcoholics Patients wi t h gastric or duodenal ulcer
• Spontaneous perforation of esophagus a f t e r vomiting
  (Boerhaave’s Syndrome)

Question 22

Cardiac Tamponade

Answer 22

• 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

Question 23

Clinical examination
of cardiac temponade

Answer 23

• Sinus tachycardia
• Elevated JVP
• Pulsus Paradoxsus
• Hypotension
• M u f f l e d heart sounds

Question 24

Echocardiography
of cardiac temponade

Answer 24

• Diastolic collapse of r i g h t ventricle and rig h t
  atrium
• Diastolic collapse of left ventricle - more
  specific

Question 25

pericarditis

Answer 25

• 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.