Download - Approach To Patient With Chset Pain
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Approach to a patient Approach to a patient with chest pain with chest pain
presenting in primary presenting in primary care settingcare setting
DR Ihab Suliman MBBS,MRCP,Diplomate
certification Board of Nuclear Cardiology(USA)
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Chest PainChest Pain
Common presentation.Trivial to life-threatening causes.Key to diagnosis is history NOT
INVESTIGATIONS.
Negative baseline investigations DO NOT ruleout serious conditions
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Life-threateningLife-threatening Causes ofCauses ofChest PainChest Pain
Myocardial infarction(ACS).Thoracic aortic dissection.Pulmonary embolus.Tension pneumothorax.Oesophageal rupture.
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Investigations
ECG most important But history is more important.
20% of patients having an MI will have a normal ECG initally.
Negative cardiac enzymes in A&E are not helpful.
CXR useful to rule out other causes like pneumonia.
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26 yr old thin man with sudden onset of severe L sided 26 yr old thin man with sudden onset of severe L sided sharp chest pain ,tachypnoeic. sharp chest pain ,tachypnoeic.
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Right Pneumothorax
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65 year old man(H/O DM,HTN) presented with a 1 hour history of 65 year old man(H/O DM,HTN) presented with a 1 hour history of severe central crushing chest pain. He is sweaty, clammy and has severe central crushing chest pain. He is sweaty, clammy and has
vomited twice .vomited twice .
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65 year old man(H/O DM,HTN) presented with a 1 hour history of 65 year old man(H/O DM,HTN) presented with a 1 hour history of severe central crushing chest pain. He is sweaty, clammy and has severe central crushing chest pain. He is sweaty, clammy and has
vomited twice .vomited twice .
Anterior (extensive) Myocardial infarction.
Why ?
Male 65 years.
H/O DM+HTN( remember INTERHEART study)
Crushing chest pain.
Associated sweaty,clammy,vomiting.
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70 years old male with long history of untreated 70 years old male with long history of untreated HTN,nonsmoker came complaining of chest pain migrated HTN,nonsmoker came complaining of chest pain migrated
to interscapular region & became severe(tearing),SBP to interscapular region & became severe(tearing),SBP 200,ECG mild inferior changes200,ECG mild inferior changes
Most likely diagnosis is? AMI?PE?Esophagear Rupture ?Aortic Dissection
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Aortic DissectionAortic Dissection•Severe, sharp, “tearing” posterior chest pain or Severe, sharp, “tearing” posterior chest pain or back pain (occurs in 74-90% of pts)back pain (occurs in 74-90% of pts)
•Pain may be associated with syncope, CVA, MI, or CHFPain may be associated with syncope, CVA, MI, or CHF
–Painless dissection relatively uncommon 15%Painless dissection relatively uncommon 15%
•Chest pain is more common with Type A dissectionsChest pain is more common with Type A dissections
•Back or abdominal pain is more common with Type Back or abdominal pain is more common with Type B dissectionsB dissections
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Physical ExaminationPhysical Examination •Pulse deficitPulse deficit
–Weak or absent carotid, brachial, or Weak or absent carotid, brachial, or femoral pulses femoral pulses
–these patients have a higher rate of these patients have a higher rate of mortalitymortality
•Acute Aortic InsufficiencyAcute Aortic Insufficiency
–Diastolic decrescendo murmurDiastolic decrescendo murmur
–Best heard along the right sternal Best heard along the right sternal borderborder
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TEE of Aortic Dissection & CT aortaTEE of Aortic Dissection & CT aorta
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40 years old male finished cardiac evaluation last week40 years old male finished cardiac evaluation last week for insurance (every thing is for insurance (every thing is
normal) .ate a heavy meal with friends (celebrating).followed by severe vomiting then chest normal) .ate a heavy meal with friends (celebrating).followed by severe vomiting then chest pain.vomitus contains streaks of fresh blood.pain.vomitus contains streaks of fresh blood.
Likely diagnosis?ACS?PE?Aortic DissectionEsophageal submucosal tear(mallory weiss
syndrome).
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A 26 year old woman presented 1 week post A 26 year old woman presented 1 week post delivery of her first baby. She has sharp L sided delivery of her first baby. She has sharp L sided
chest pain and she is short of breath.chest pain and she is short of breath.
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Pulmonary EmbolismWhy ?Young femalePegnancy hypercoagulable stateOccurrence one week post partum
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50 years old female with chronic renal failure,chest 50 years old female with chronic renal failure,chest pain & dizzinesspain & dizziness
she is hypertensive on lisinoprilshe is hypertensive on lisinopril
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Hyperkalemia,tall tented T-wave & bradycardia.
Why ?Chronic renal failurePatient on lisinopril
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26 Old army officer had flu last week,felt chest pain while driving his 26 Old army officer had flu last week,felt chest pain while driving his car,pain increased by deep breath,he has no history of DM or car,pain increased by deep breath,he has no history of DM or
HTN,nonsmoker,lipid profile LDL 2.0 MMMOL/HTN,nonsmoker,lipid profile LDL 2.0 MMMOL/LL
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Acute Pericarditis
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26 Old army officer had flu last week,felt chest pain 26 Old army officer had flu last week,felt chest pain while driving his car,pain increased by deep breath,ECG while driving his car,pain increased by deep breath,ECG
after 5 daysafter 5 days..
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Resolved Pericardtis.
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Diagnostic limitationsHistory:
25% have ‘atypical’ histories
ECG:
55% of pts with AMI have a normal 1ST 12-lead ECG
Convential Cardiac Markers:
Normal for the first 3- 4 hours
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Take home points•History 90%
•ECG: if ST elevated act fast
•Risk factor reduction
•Never ignore chest pain