Transcript Slide 1

BY NADIA RAHATI TALAB
SECOND YEAR RESIDENCY
APPROACH TO CHEST PAIN
Objective
 Establish a differential diagnosis for chest
pain
 Know what clues to obtain on history rule in
or out MI ,PE, pneumothorax ,and aortic
dissection
 Identify risk factors for MI
 Know how to do a focused physical exam .
identifying features that would distinguish
between MI ,PE ,pneumothorax and aortic
dissection
Etiologies
 Myocardial ischemia or infarction
 Pulmonary embolus
 pneumothorax
 Tamponad
 Pneumonia
 Aortic dissection
 Gastritis ,peptic ulcer disease
Important
 As a general rule any chest pain is ischemie in
origin until proven otherwise
Myocardial ischemia or
infarction
 Pressure_type of chest pain
 Generally involves central to left sided pain
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with radiation to jaw or arms
Exacerbated by activity ,releived with rest
Relieved with nitro spray
Associated with nausea ,syncope,
diaphoresis,shortness of breath
Risk factors: age,sex,smoking ,diabets
,hypertention ,hyperlipidemia,family history
Myocardial ischemia or
infarction
 Low blood pressure indicates cardiogenic
shok
 Elevated jvp ,pulsatile liver and peripheral
edema seen in right sided heart failure
 Oxygen desaturation ,crackles ,s3 seen in left
sided heart failure
 New murmurs :mitral regurgitation murmur
in papillary muscle dysfunction
Work up
EKG
CXR to look for signs of congestive heart failure
Cardiac enzymes :CK ( will begin to rise 6
houres after infarct and remain elevated for
24 _48 hours)troponin will rise 12 hours after
infarct and remain elevated for two weeks
,need to follow serially if firs set negative
Management strategy for
STEMI
 Morphine,oxygen,nitro,aspirin
 Beta blocker ,Ace inhibitors
 Early invasive strategy with either
thrombolytic therapy or percutaneus
coronary intervention
Pulmonary embolism
 Sudden sharp chest pain
 Exacerbated by inspiratory effort
 Can be associated with hemoptysis
,syncope,dyspnea,dvt
 Risk factors:
 post operative
complications,hypercoagulatable,immobiliza
tion,fracture of a limp
Pulmonary embolism
 Anxious
patient,tachycardia,tachpnea,hypoxia
 ECG: sinus tachycardia most common
,S1Q3inverted T3 and some times right axis
deviation
 Spiral CT with contrast show large ,central
emboli
 Consider Doppler u/s of legs
What is your diagnose
pneumothorax
 Can be asymptomatic or present with acute
pleuritic chest pain and dyspnea
 Primary pneumothorax in young tall males
 Due to trauma
 Rupture of bleb in COPD patients
Aortic Dissection
 Abrupt onset
 The pain is like ripping and tearing that is felt
in the intrascapular area
 New diastolic mur mur ,asymetrical pulses
and asymmetrical blood pressure
 Risk factors:HTN,marfan syn,
 Widened mediastinum on a
portable(ap)radiography
Case 1
 A64 year old woman is valuated in the emergency
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department 6 hours after the onset of severe crushing chest
pain associated with diaphoresis ,nausea,and vomiting.her
medical history is significant only for mild hypertention her
medication includes atrovastatin and aspirine .her blood
pressure is 150/88 .and her pulse rate is 88 .the lungs are
clear she has no murmur examination of the abdomen and
extremities is normal what is the best step next step in the
management of this patient?
CXR
EKG
Cardiac enzymes
CBC
Signs:
 EKG shows a 3mm ST _segment elevation in
lead II,III and AVF,with occasional premature
ventricular contractions ,cardiac enzymes are
elevated what is the best next step in the
management
Treatment:
 Thorombolytic therapy
 Coronary angiogram
 Beta blocker
 Amiodarane
Case 2
 A 72 year old men is evaluated in the
emergency department for the sudden onset
sever sharp anterior chest pain radiating into
the back .He is former smoker with along
history of type 2 diabetes ,chronic renal
insufficiency ,sick sinus syndrome with a DDD
pacemaker implanted and hypertension and
his medication includes insulin ,furosmide
and aspirine
Case 2
 On examination the blood pressure is
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180/85and the pulse rate is 90 and regular
there are abdominal and bilateral femorl
bruits with absent distal pulse his EKG is
normal which of the following is most
appropriate initial imaging study?
Non_ contrast chest CT
Chest MRI
Transesophageal echocardiography
Transthoracic echocardiography
Thank you