BY NADIA RAHATI TALAB SECOND YEAR RESIDENCY

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 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

EKGCXR to look for signs of congestive

heart failureCardiac 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,immobilization,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 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 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