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Chest Pain-case 2

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Common clinical case scenario @ Emergency department about chest pain

Common clinical case scenario @ Emergency department about chest pain

Published in Health & Medicine
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  • 1. Case 2-Chest Pain Alifah & Liyana Faculty of medicine UiTM,Malaysia
  • 2. History
    • Mdm. Xx, 60 y.o, chinese lady known case of HPT and DM for 10 years.
    • Complaint of chest pain on the day of admission.
      • Site : Central
      • Nature : Tightness
      • Radiation : jaw and left arm
      • Duration : 20 minutes
      • Aggravating factor : -
      • Relieving factor : GTN ( KK)
      • Associated symptom : nausea, sweating, dyspnoea,
  • 3.
    • Past Medical History
    • DM , HT  10 years
    • Surgical History
    • Nil
    • Drug History
    • For HT & DM
    • Allergy
    • Nil
    • Family History
    • +ve hx of HT, DM, heart problem
    • Social History
    • Smoker (5sticks/day)
    • Occasional drinker
    • Diet history
    • - High fat food
  • 4. PHYSICAL EXAMINATION
    • Vital Signs:
    • BP:135/95 mmHg
    • HR:92 beats/minute (regular rhythm and volume)
    • RR: 22 breaths/minute
    • General examination - obese
  • 5. Cardiovascular system
    • Inspection:
    • On inspection, there is no deformity, no dilated vein, no surgical scar, and no visible pulsation.
    • Palpation:
    • The apex beat is not palpable. There was no parasternal heave. Thrills were also absent.
    • Auscultation:
    • S1 and S2 were heard. There was no radiation, no murmur, no rubs and no additional sounds. S3 and S4 were not heard. There was no carotid bruit present. The 1 st and 2 nd maneuver (mitral stenosis and aortic regurgitation) reveals no significants findings.
  • 6. Provisional diagnosis
    • Non ST elevation myocardial infarction (NSTEMI) / unstable angina
    • History :
    • Central chest tightness :
    • Radiated to jaw & left arm
    • 20 minutes
    • Relieved by GTN
    • Associated with : nausea, sweating, dyspnoea
    • Known case of DM & HT ( 10 years )
    • +ve family hx of heart problem
    • Smoker ( 20 years)
    • fat food diet
    • PE :
    • -obese
  • 7. Differential Diagnosis
    • 1. Acute myocardial infarction
    • Points to support :
    • Points to against :
    •  ECG : ST segment depression
    •  Relieved by GTN
    •  Duration : 20 minutes
    • 2. Aortic dissection
    • Points to support :
    • severe, sudden chest pain
    • History of HT & DM
    • Points to against :
    • Chest Pain : tightness, not radiate to the back
    • No syncope
    • CXR : no boarding of upper mediasternal & distortion of aortic knuckle, no right sided pleural effusion & left ventricular hypertrophy
  • 8.
    • Pulmonary embolism
      • Pros :chest pain associated with shortness of breath
      • Cons :no hemoptysis and no risk factor of hyper-coagulability like prolong bed rest.
    • Pericarditis
      • Pros :the patient present with chest pain
      • Cons :the pain not aggravated by changes in posture like leaning forward.
  • 9. investigation
    • General :
    • FBC, BUSE : no significant finding
    • PT, PTT : normal
    • CXR : normal ( No cardiomegaly, perihilar haziness and lung fields were clear)
  • 10.
    • Cardiac enzymes
    • elevation of :
    • Troponin T
    • CKMB
    • Lipid Profile
    LIPID VALUE NORMAL RANGE REMARKS Total cholesterol 6.6 <5.17 mmol/L Increase Triglyceride 1.5 0.45 – 1.5 mmol/L Normal HDL 1.2 1.0 – 1.79 Normal LDL 4.7 < 3.4 mmol/L Increase
  • 11. ECG
    • ST segment depression
    • T inversion
  • 12. Final diagnosis
    • Non ST elevation myocardial infarction (NSTEMI)
    • Points to support :
    • Central chest tightness :
    • Radiated to jaw & left arm
    • 20 minutes
    • Relieved by GTN
    • Associated with : nausea, sweating, dyspnoea
    • Known case of DM & HT ( 10 years )
    • +ve family hx of heart problem
    • Smoker ( 20 years)
    • fat food diet
    • PE : overweight
    • IV
    • Lipid profile :
    • increase LDL & total cholesterol
    • Cardiac enzyme :
    • Troponin T & CKMB
    • ECG :
    • ST segment depression & T
    • inversion
  • 13. Management of acute coronary syndrome ( NSTEMI)
  • 14.  
  • 15. Criteria for high & low for death or MI
    • High risk
    • ECG abnormalities
    • Dynamic ST segment changes > 0.05 mV, particularly ST segment depression
    • Transient ST segment elevation
    • T wave inversion > 0.2 mV
    • Pathological Q wave
    • Bundle branch block
    • Sustain Ventricular tachycardia
    • Elevated Troponin level
    • Low Risk
    • No recurrence of chest pain within the observational period
    • No ST segment depression or elevation but rather negative T wave, flat T wave or normal ECG
    • Without elevation of Troponin or other biomarker of cardiac injury
  • 16.
    • High Risk
    • Low risk
  • 17. Management
    • Post hospitalization
    • Medical therapy ( compliance )
    • Life-style modification
    • : Diet : highly oily fish, fruit, vegetable, fiber & low fats
    • : Exercise : Regular daily exercise
    • : Avoid air travel for 2 months
    • : Reduce & stop smoking
    • - Follow up ( after 3 & 5 weeks )
  • 18. references
    • Sarawak Handbook of medical emergencies
    • Oxford Handbook of clinical medicine
    • Davidson’s, Principle & practice of medicine