Date post: | 22-Dec-2015 |
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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