Week 2- Chest pain

Question 1

Mr. Ben B. 55-year-old man from Innisfail, brought in by his wife Enid, following an episode of anterior chest pain yesterday and another brief episode this morning
Take a history from the patient

HPC:
4/10 continuous pain lasting 40 min, pain increased to 8/10 Pain radiating down jaw and left arm, started when watching TV With Nausea and diaphoretic Today and yesterday Not relieved by Maylanta (H2 antagonist)First presentation Sick in past 3 days ago, with dry cough, febrile, myalgia, taken Panadol

PMHX:
Hypertension Diabetic Dyslipidaemia High BMI

FHX:
Mother stroke Dad MI 48ys Brother hypertension

SHX:
Smoking for past 40ys 10 cig/day = 20 pack /year Etoh 6 beer per week Nutrition: no fruits, No exercise

Answer 1

HPC:

• How long has the pain been for
• Did it come on quickly/what were you doing?
• Character- tightness, sharp, crushing, dull
• Location- substernal, central chest
• Radiation
• Alleviating factors
• Have you experienced this before
• Associated symptoms- fever, SOB, nausea, diaphoresis, palpitaitons, orthopnea, PND
• Effect on lifestyle

PMHx:

• Previous MI
• Dyslipidaemia
• Hypertension
• Cardiac valve surgery
• Arrhythmias
• Recent viral infections
• Recent MSK trauma

PSHx:
-Any past surgeries

Medications- any regular meds
Allergies- agent and reaction
Immunisations- fluvax, pneumoccocal

FHx:
-Family history of any cardiac conditions

SHx:

• Background
• Occupation
• Education
• Religion
• Living arrangements
• Smoking
• Nutrition- high in fat/salt
• Alcohol/recreational drugs
• Physical activity- potentially limited

Systems:

• General; weight loss, fever, chills, night sweats
• CVS; palpitations, chest pain, orthopnea, PND
• RS: dyspnoea, cough, sputum, wheeze
• GI: vomiting, diarrhoea, constipation, abdo pain, dysphagia
• UG: dysuria, polyuria, nocturia, urgency, incontinence
• CNS: headaches, nausea, trouble with hearing/vision
• ENDO: heat/cold intolerance, swelling in neck/throat, polydipsia/polyuria
• HAEM: easy bruising, lumps in axilla/neck/groin
• MSK: painful or stiff joints, muscle aches, rash

Question 2

Perform an examination on this patient

Answer 2

General Inspection→

• Cachectic→ CF,
• Posture→ marfaans syndrome (rare in females)
• Alert and orientated→ altered in IE
• Diaphoresis? Anxiety? BMI
• Any obvious scars indicative of previous cardiac surgery (can also be done in inspection of chest but good to comment)
• any pacemakers, defibs (can also be done in inspection of chest but good to comment)

Vital signs→

• Temp→ raised in myocarditis
• Pulse→ regular, irregular, regularly irregular, tachycardic→ AF
• BP→ high or low in MI
• RR→ may be elevated if anxious/in pain
• BMI/BSL

Hand inspection→
-Nails→ cap refill (anaemia), pallor (anaemia)
-Hands→ temp (cool in cardiac failure), palmar crease pallor (anaemia)
Arms→ oedema (CF), xanthomata

Face inspection→
Eyes→ conjunctival pallor (anaemia), xanthoma
Face→ malar flushing (if in cardiac failure, blood pressure back flow into face to cause flushing)
Mouth→ mucosal hydration, cyanosis

Neck inspection→
JVP→ elevated (above 3cm in LV failure or valve dysfunction), potential kussmauls sign (rise in JVP on insp)
Carotid→ murmur radiates to carotid in aortic stenosis

Chest inspection→
Apex beat→ may be displaced in cardiomegaly (due to LV hypertrophy), tapping qualities (present with a murmur)
Auscultation→ potential soft heart sounds, S3 and S4 may be heard
-Transient apical midsystolic or late-systolic murmur (due to regurg)
-Potential murmurs (due to valve rupture)

Back inspection–>

• Inspection- scars, deformity, erythema
• Palpation for sacral oedema
• Percuss lung bases for dullness- heart failure
• Auscultation

Abdominal inspection:
Liver→ hepatomegaly (in cardiac failure)
Spleen→ splenomegaly (in IE)
Masses, pulsations

Leg exam:
Oedema→ in CF- backflow
CRT, clubbing, splinter haemorrhages, peripheral pulses

Resp exam:
Chest→ crackles (CF)

Neuro exam:
Cranial nerve functions/motor sensory test

Question 3

What investigations would you like to perform

Answer 3

ECG
Serum Lipids
Electrolytes, urea and creatinine
CXR
Troponin I, CKMB
FBC- platelets
Angiography

Question 4

What is the treatment

Answer 4

Assuming MI;

• M= morphine; pain relief–>relieves adrenergic stimulation
• O= oxygen
• N= nitrates–> Sublingual GTN – first aid measure in UA or threatened infarction, IV Nitrates – to treat LV failure or persistent cardiac pain, IV B-Blockers – reduce arrhythmias and reduce workload on heart, do NOT use if in HF/bradycardia, Calcium channel antagonists – alternative to B-blocker, Statin- aids in plaque stabalisation
• Don’t use aspirin in RV damage–> GTN is used to decrease venous pooling so decrease workload on heart–> if pt has RV damage the pooling of blood in the right side aids in increase pre-load and increasing CO
• A= aspirin + ticagrelor–> anticoagulants to reduce the risk of thromboembolism and prevent re-infarction
• Reperfusion–> using thrombolysis (tissue plasminogen activase (TPA)) to remove the clot, or percutaneous coronary intervention (PCI)(placing a stent) –> within 1h

Question 5

What is the provisional and differential diagnosis

Answer 5

Provisional; ACS (MI, unstable angina)
DDx; Aortic dissection, PE, Cardiac Tamponade, Tension Pneumothorax, Oesophageal Tear, Trauma, pneumonia, GORD, Anxiety, Pleurisy