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TRANSCRIPT
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CHIEF COMPLAINT:
Chest Pain
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Chest Pain
• Unpleasant sensation in the chest or thoracic area– Tightness, pressure or pain
starting in the middle of the chest and often radiating to other anatomical structures in the upper part of the body
Stedman’s Medical Dictionary 27th Edition
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Chest Pain
Pulmonary
Gastrointestinal
Musculoskeletal
Others
Cardiovascular
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Myocardial Ischemia and Injury
Angina pectoris
Unstable Angina
Acute myocardial infarction
Aortic stenosis
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Chest Pain
Non-ischemic Ischemic
Image retrieved from: http://www.pain-free.eu
• Pericarditis• Aortic dissection• Pulmonary embolism
• Angina• Unstable Angina• Myocardial Infarction• Aortic Stenosis
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Cardiovascular System
Chest Pain
Pericarditis
Pulmonary
Embolism
Aortic Dissection
AnginaUnstable Angina
Myocardial Infarction
Aortic Stenosis
Reference: Harrison’s Principles of Internal Medicine 17th edition
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Gastrointestinal System
Acid
Reflux
Esophageal Spasm
Trauma - Esophagus
Referre
d PainChest Pain
Reference: Mosby’s Guide to Physical Examination, 6th edition
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Respiratory System
Embolism
Pneumothorax
Hydrothorax
Infection /
InflammationChest Pain
Reference: Mosby’s Guide to Physical Examination, 6th edition
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Musculoskeletal System
Chest Pain
Compression of nerve roots
Referred pain
TraumaIntercostals
muscle cramps
Infection / Inflammation
References: Mosby’s Guide to Physical Examination, 6th edition. Harrison’s Principles of Internal Medicine 17th edition
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Psychoneurotic System
Chest Pain
Stress Panic attack
Emotional Depression
Illicit drug use
Long term effect of
marijuana
References: Mosby’s Guide to Physical Examination, 6th edition. Harrison’s Principles of Internal Medicine 17th edition
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Condition Duration Quality Location Associated Features
Angina More than 2 and less than 10 min
Pressure, tightness,
squeezing, heaviness,
burning
Retrosternal, often with radiation to or isolated discomfort
in neck, jaw, shoulders, or arms – frequently on left
Precipitated by exertion, exposure
to cold psychological
stress
Unstable Angina 10-20 minSimilar to angina but often more
severeSimilar to angina
Similar to angina, but occurs with
low levels of exertion or even at
rest
Acute Myocardial Infarction
Variable; often more than 30 min
Similar to angina but often more
severeSimilar to angina
Unrelieved by nitroglycerin; may be associated with evidence of heart
failure or arrythmia
Aortic Stenosis
Recurrent episodes as described for
angina
As described for angina
As described for angina
Late-peaking systolic murmur
radiating to carotid arteries
Reference: Harrison’s Principles of Internal Medicine 17th edition
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Reduced size of lumen –artherosclerosis
Anemia
Art
eria
l th
rom
bi
Coronar
y emboli
LV hyp
ertro phy se
conda ry
to hyp
erte nsion
ISCHEMIA
Reference: Harrison’s Principles of Internal Medicine 17th edition
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LABORATORY TESTS & other ancillary procedures
LABORATORY EXAMINATIONS
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Reference: Harrison’s Principles of Internal Medicine 17th edition
Cardiovascular Disorders
Enzyme markers
Lipid Profile
ECG Non-invasive cardiac imaging
Routine tests for non-specific
inflammation
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Electrocardiography
• A graphic recording of electric potentials generated by the heart
• Signals are detected by means of metal electrodes attached to the extremities and the chest wall
• These signals are amplified and recorded by an electrocardiogram
• Adv. : non-invasive, inexpensive, highly versatile• Uses : detect arrhythmias, conduction disturbances, and MI
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ECG TRACING
Lead V4 at rest (top) and after 4½ min of exercise (bottom). There is 3 mm (0.3 mV) of horizontal ST-segment depression,
indicating a positive test for ischemia.
Reference: Harrison’s Principles of Internal Medicine 17th edition
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2D ECHOCARDIOGRAPHY
• Uses the principle of ultrasound reflection
of cardiac structures to produce images of
the heart
• Ideal imaging modality for assessing left
ventricular size and function
• Useful in the diagnosis of LV hypertrophy
Reference: Harrison’s Principles of Internal Medicine 17th edition
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ENZYME MARKERS IN CARDIAC INJURY
Reference: Clinical Chemistry, principles, procedures, correlations 4 th ed.
Enzyme Onset of Elevation
Peak Levels Duration of Elevation
CK-MB 4-8 hours 12-24 hours 3-4 days
AST 8-12 hours 24 hours 5 days
LDH 12-24 hours 72 hours 10 days
Troponin T Few hours 48 hours 5 days
Troponin I (only found in the
myocardium of adult humans)
3-8 hours 12-24 hours 5-10 days