Post on 12-Apr-2017
transcript
Approach to Chest Pain
Approach to Chest PainDone By Abdulwahab K NeyaziMBBS
ContentIntroductionBrain StormingDDxCardiac OriginRespiratory OriginGI Origin
IntroductionChest pain is very common complain either in clinic, ER, or Word.
Taking detailed history Is Important.
You have to take it series.
IntroductionOnset.Duration.Progression. Aggravating and Relieving Factors. Nature.Radiation.Severity of the pain Limitation of the usual activity.
Cautions
SMART patients
Brain Storming
HxDDX
DDx
DDx
DDx
DDx
Musculoskeletal Most Common Cause of Chest pain
Usually pain is localized.
Strained chest muscles from overuse or excessive coughing.
Chest muscle bruising from minor injury.
MusculoskeletalTreatment
Analgesic
Cardio-VascularA - Coronary artery disease
Stable angina pectoris
Unstable angina
Non-ST elevation myocardial infarction.
ST elevation myocardial infarction.
This is defined as substernal discomfort precipitated by exertion, typically radiating to the shoulder, jaw, or inner aspect of the arm, and relieved by rest ornitroglycerinin less than 10 minutes
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A - Coronary artery diseaseCardiac EnzymeECG Chest pain Duration-venormalLess than 10 minAngina-veNo ST Changes> 10 minUnstable Angina+veST depression> 10 minNSTEMI+veST elevation> 10 minSTEMI
A - Coronary artery disease
What Do You Think
ATYPICAL PRESENTATIONOLD Age
DM
TreatmentAcute managements
MONA B (Morphine O2 Nitrates Aspirin Beta blocker )
Clopidogrel
Heparin
PCI or CABG
TreatmentRisk Factors Modification
Smoking
HTN
Hyperlipidemia
DM
Diet
B Aortic Dissection
Severe Tearing/ Stabbing pain
Sudden onset
Anterior radiating to the Back
Clinical Finding
Hypertensive
Pulse or BP asymmetry between limbs
Aortic regurgitation
Predisposing FactorsHTN
Connective tissue disease (Marfans)
Coartation of the Aorta
Trauma
Cocaine
Stanford ClassificationType AInvolve Ascending aorta
Type BInvolve Descending aorta
BA
DiagnosisCXR>8mm
DiagnosisCT or MRI
Diagnosis
TEE ( High Sensitivity and Specificity )
Aortic Angiography
TreatmentInitial therapy
IV B-Blocker
Control BP
TreatmentType ASurgical intervention
Type BControl BP by IV e.g. Labetalol, or Propranolol.Control Pain with morphine.
C - Pericarditis
Define as inflammation of pericardial sac
EtiologyIdiopathic
Infection
Acute MI
Uremia
Neoplasm (Hodgkin Lymphoma, breast and lung Ca)
Clinical FeaturesChest pain
Severe Pleuritic localized
Aggravated by lying supine, coughing swallowing and deep inspiration.
Relieved by sitting up and leaning forward.
It might be preceded by viral illness.
ExaminationPericardial Friction Rub
DiagnosisECG
Diffuse St elevation and PR depression
DiagnosisEchoPericardial effusion
ComplicationPericardial effusion
Cardiac Tamponade
Becks TriadHypotension - Muffled Heart sound - High JVP
TreatmentSelf limited resolved in 2-6 weeks.
NSAID.
If effusion small, repeat Echo in 1to 2 weeks.
Pericardiocentesis.
Respiratory A - PE
B Tension pneumothorax
Pulmonary Embolism Source of Emboli
A - Lower extremity DVT
B - Upper extremity (drug abusers)
Clinical FeaturesSOB
Pleuritic Chest pain
Cough
Hemoptysis
Tachypnea and Tachycardia
Modified Wells Criteria
DiagnosisABGRespiratory Alkalosis (due to hyperventilation).
Doppler for DVT.
Spiral CT.
V/Q Scan (ventilation perfusion lung).
TreatmentO2
Anticoagulation therapy
Heparin and Warfarin (target INR 2-3)
How to use Warfarin
Warfarin Tips
TreatmentThrombolytic !! (No evidence for improving mortality)
But !Can be considered :Pt with massive PE who are unstable (persistent hypotension )OrPt with evidence of Right heart failure
Tension Pneumothorax
Accumulation of the air within the pleural space
Clinical FeaturesSOB
Chest pain tightness
Hypotension
Distended neck veins
Trachea shifting
Decrease breathing sound on affected side
Hyperresonance on percussion
CausesTrauma
CPR
Mechanical Ventilation with associated barotrauma
Iatrogenic e.g. Central line insertion
DiagnosisDiagnosed Clinically (Hx and Examination)
CXR
TreatmentChest Decompression
Chest tube
Gastro IntestineA Gastro Esophageal Refluxes
B Esophageal Spasm
C Peptic Ulcers
Gastro Esophageal Refluxes
GERD very common.Its prevalence increase with age
Etiology
Multifactorial causes :-In appropriate relaxation of LES.Decrease motility.Hiatal hernia.Gastric outlet obstruction.
Clinical FeaturesHeartburn, retrosternal pain shortly after eating
Aggravated by lying down after meals
Cough
Sore throat
DiagnosisClinically by Hx
24h PH monitoring in the lower Esophagus (Gold Stander)
Endoscopy
Upper GI series barium study
ComplicationsErosive Esophagitis
Esophageal Ulcers
Barrett's Esophagus
Aspirational Pneumonia
TreatmentBehavior modification
H2 blockerPPIMetoclopramide
Surgery
Summary
ReferencesUptodate.comMedscape.orgStep-up medicineWashington
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