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Differential diagnosis of chest pain by dr farooq on 29 02-30 h.
 

Differential diagnosis of chest pain by dr farooq on 29 02-30 h.

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  • In spite of the many innovations over the years and the huge influx of technology into medicine and cardiology, the evaluation of acute chest pain remains an important and challenging task for the physician today. It leads to more than 5 million ER visits annually and more than 8 billion dollars in hospitalization costs each year. And while on one hand less than a third of patients with chest pain are found to have a cardiac etiology, a not insignificant number of patients discharged from the ED turn out to have unrecognized acute MI
  • So our goal, then, is minimize the cost and hospitalization of patients with chest pain of benign etiology, but to rapidly and accurately recognize and treat those with true acute coronary syndromes.
  • There are many ways chest pain can be approached, ranging from use of clinical clues, cookbook algorithms, computer guided algorithms, and finally, the use of dedicated chest pain centers. Each approach will now be reviewed.
  • Lecture Notes On initial examination, Q-wave AMI may masquerade as another ACS (eg, unstable angina or non–Q-wave MI) or vice versa. Distinguishing AMI from another possible ACS is important as fibrinolytic therapy has not been proved beneficial for other forms of ACS and entails a bleeding risk.

Differential diagnosis of chest pain by dr farooq on 29 02-30 h. Differential diagnosis of chest pain by dr farooq on 29 02-30 h. Presentation Transcript

  • WELCOME TO CME CFH
  • IN THE NAME OF ALLAH THE MOST GRACIOUS,THE MOST MERCIFUL
  •  
  • DIFFERENTIAL DIAGNOSIS OF CHEST PAIN DR.MUHAMMAD FAROOQUE MB BS DTCD
  • Chest Pain
    • 5 Million emergency department visits
    • 2 million hospitalizations annually with cost of more than $8 billion
    • Cardiac etiology found in less than one third
    • 2% of patients with acute MI are unrecognized and discharged from the ED
  • Goals
    • Rapid recognition of management of true ACS
    • Recognition of other life-threatening causes of chest pain
    • Minimize cost and hospitalization in patients with chest pain of benign etiology.
  • Chest Pain Diagnosis
    • Clinical diagnosis
    • Diagnosis using computer algorithms
    • Chest pain centers
  • CHEST PAIN (1429)
    • TOTAL PATIENTS=544
    • IHD= 518
    • CCF= 19
    • MI DIAGNOSED ON ECG =7
    COURTESY: HAMAD RASHID AL-MONAJAM
  • PAIN JUST A CURSE OR A MERCY OF GOD
  • PAIN?
    • UNIVERSALLY UNDERSTOOD AS “DISEASE SIGNAL”
    • MOST COMMON SYMPTOM THAT BRINGS A PATIENT TO A PHYSICIAN`S ATTENTION.
    • AN UNPLEASANT SENSATION LOCALIZED TO A PART OF THE BODY
    • ITS BOTH SENSATION AND EMOTION
  • ITS BOTH SENSATION AND EMOTION
    • ACCOMPANIED BY ANXIETY
    • ACCAMPANIED BY URGE TO ESCAPE OR TERMINATE THE FEELING
    DUALITY OF PAIN PAIN
  • PAIN HOW DESCRIBED?
    • STABBING
    • BURNING
    • TWISTING
    • TEARING
    • SQUEEZING
    • TERRIFYING
    • NAUSEATING
    • SICKENING
    PENETRATING OR TISSUE-DESTRUCTIVE PROCESS BODILY OR EMOTIONAL REACTION
  • ACUTE PAIN
    • BEHAVIORAL AROUSAL
    • STRESS RESPONSE
    • LOCAL MUSCLE CONTRACTION
    INC BP INC HR INC PUPIL DIAMETER INC PLASMA CORTISOL LEVEL ASSOCIATED WITH
  • PAIN IN THE CHEST BUT ORIGIN??
    • HEART
    • LUNGS
    • OESOPHAGUS
    • MUSCULOSKELETAL STRUCTURES OF THORAX NECK,OR SHOULDER
    • ABDOMEN
    • ANXIETY MANIFESTATION
  • CHEST PAIN CLASSIFICATION FROM CLINICAL VIEW POINT: RECURRENT OFTEN PAROXYSMAL MILD OR MODERATE ANGINA MUSCULOSKELETAL PAINS SEVERE PROLONGED ASSOCIATED WITH CLINICAL EVIDENCE OF ACUTE SERIOUS ILLNESS 1 2
  • WHAT LIES IN THE CHEST?
    • SKIN
    • MUSCLES
    • BONES
    • JOINTS
    • HEART AND VESSELS
    • LUNGS AND AIRWAYS
    • OESOPHAGUS
    • NERVES
  •  
  •  
  • CHEST PAIN ASSESSMENT
    • HISTORY
    • EXAMINATION
    • ECG
    • CARDIAC ENZYMES
    • CXR
    • OTHERS
  • INITIAL APPROACH
    • Assume the worst!
    • 100% Oxygen
    • IV access
    • Monitoring
    • ECG quickly
    • Done in tandem with history taking
  • TIME IS VITAL
  • CHEST PAIN
    • COMMON PRESENTATION TO A&E
    • TRIVIAL TO LIFE-THREATENING CAUSES
    • KEY TO DIAGNOSIS IS HISTORY
    • NEGATIVE BASELINE INVESTIGATIONS DO NOT RULE OUT SERIOUS CONDITIONS
    • HEART ATTACK
    • ANSWER IS NO ……
    • RELAX
    • IS IT ENOUGH TO RULE OUT HEART ATTACK?
    LIFE THREATENING CHEST PAIN IN THE EMERGENCY DEPARTMENT
  • Life Threatening Chest Pain in the Emergency Department
    • • Myocardial Infarction
    • USA
    • • Aortic Dissection
    • • Tension Pneumothorax
    • • Pulmonary Embolus
    • • Ruptured Esophagus/Perforated Ulcer
  • COMMON CAUSES OF CHEST PAIN
    • ANXIETY
    • CARDIAC
    • AORTIC
    • OESOPHAGEAL
    • LUNGS/PLEURA
    • MUSCULOSKELETAL
    • NEUROLOGICAL
    MYOCARDIAL ISCHEMIA(ANGINA) MI MYOCARDITIS PERICARDITIS MVP AORTIC DISSECTION AORTIC ANEURYSM ESOPHAGITIS ESOPH SPASM MW SYNDROME BRONCHOSPASM:::::PE:::PI PNEUMONIA:::::TB:::::::CTDs TRACHEITIS PLEURITIS PNEUMOTHORAX MALIGNANCY OA RIB # I/C MUSCLE INJURY TEITZE`S SYND BORNHOLM`S DISEASE PROLAPSED I/V DISC HERPES ZOSTER THORACIC OUTLET SYNDROME
  • CARDIAC OR NON-CARDIAC PAIN?
  • Chest Pain: History
    • P: pattern (temporal sequence)
    • A: associated features
      • SOB, N/V, diaphoresis
      • fever, cough, chills
      • abdominal pain
    • I: initiation and improvement
    • N: nature (quality)
  • CHEST PAIN ASSESSMENT
    • History VITALLY IMPORTANT
    • PAIN
    • NATURE
    • SITE
    • SEVERITY
    • RADIATION
    • ONSET
    • EXAC/RELIEVING FACTORS
    • ASSOCIATED FEATURES
    • DURATION
    • PREVIOUS SIMILAR PAINS
  • Chest Pain: Physical Exam
    • Vital signs and general appearance
    • Carotids and JVP
    • Lungs
    • Cardiac exam
    • Thoracic cage
    • Abdominal exam
    • Periphery (pulses)
    • Skin
  • CHEST PAIN ASSESSMENT
    • Examination
    • General Examination
    • ( sweaty clammy pale cyanosed, anaemic etc pulse BP)
    • Cardiovascular /Respiratory examination
    • ? Failure ( crackles ,oedema, raised JVP)
    • Heart Sounds
    • - rate , nature ,?quiet ? added heart sounds, ?murmurs
  • Chest Pain: Location Myocardial ischemia Pericarditis Pleurisy, Sub-diap abscess Myocardial ischemia Cervical spine Thoracic outlet Pulmonary embolism Pneumonia Splenic infarction Subdiap. abscess Myocardial ischemia Pericarditis Aortic dissection Mediastinal lesion Pulmonary embolism Esophageal spasm Cholecystitis Hepatic distension Peptic disease Pancreatitis Myocardial ischemia
  • ISCHEMIC CARDIAC PAIN NON-CARDIAC PAIN V/S LOCATION CENTRAL, DIFFUSE PERIPHERAL LOCALIZED RADIATION JAW/NECK/SHOULDER/ OCCASIONALLY BACK OTHER OR NO RADIATION CHARACTER TIGHT SQUEEZING CHOKING SHARP STABBING CATCHING PRECIPITATION EXERTION EMOTION SPONTANEOUS NOT RELATED TO EXERTION PROVOKED BY POSTURE, RESPIRATION OR PALPATION RELIEVING FACTORS REST NITRATES NOT RELIEVED BY REST SLOW OR NO RESPONSE BY NITRATES ASSOCIATED FEATURES BREATHLESSNESS RESP; GIT,LOCOMOTOR, OR PSYCHOLOGICAL
  • MYOCARDIAL ISCHEMIA(ANGINA) MI MYOCARDITIS PERICARDITIS MVP AORTIC DISSECTION AORTIC ANEURYSM ESOPHAGITIS ESOPH SPASM MW SYNDROME BRONCHOSPASM:::::PE:::PI PNEUMONIA:::::TB:::::::CTDs TRACHEITIS PLEURITIS PNEUMOTHORAX MALIGNANCY OA RIB # I/C MUSCLE INJURY TEITZE`S SYND BORNHOLM`S DISEASE PROLAPSED I/V DISC HERPES ZOSTER THORACIC OUTLET SYNDROME
  • ANXIETY
    • ANXIOUS THOUGHTS
    • AVOIDANCE BEHAVIOUR
    • SOMATIC SYMPTOMS
    • STRESS
    • H/O UNPLEASANT INCIDENCE
    • HYPERVENTILATION
    • BREATHLESSNESS
    • PALPITATION
    • CHEST PAIN
    • HEADACHE
    • TINGLING SENSATION
    • NAUSEA
    • LBM
    • URINARY FREQUENCY
  • ISCHEMIC CARDIAC PAIN ORIGIN? SITE OF ORIGIN OF PAIN CENTRAL
  • ISCHEMIC CARDIAC PAIN
    • MAY RADIATE TO NECK
    • JAW
    • UPPER OR LOWER ARM
    • BACK
    RADIATION
  •  
  • ISCHEMIC CARDIAC PAIN
    • PLEURAL PROBLEMS
    • LUNG PROBLEMS
    • MUSCULOSKELETAL
    • ANXIETY
    PAIN RADIATION OTHER POSSIBILITIES
  • ISCHEMIC CARDIAC PAIN OR DISCOMFORT
    • TYPICALLY DULL
    • CONSTRICTING
    • CHOKING
    • HEAVY
    • USUALLY DESCRIBED BY PATIENTS AS---SQUEEZING— CRUSHING---- BURNING------- ACHING BUT NOT SHARP BUT NOT STABBING BUT NOT PRICKING BUT NOT KNIFE-LIKE
    • SENSATION CAN BE DESCRIBED AS BREATHLESSNESS
    CHARACTER OF PAIN
  • ISCHEMIC CARDIAC PAIN OR DISCOMFORT
    • EXERTION
    • EMOTIONS
    • LARGE MEALS
    • COLD WIND
    • UA AT REST
    • LYING DOWN (DECUBITUS ANGINA)
    PROVOCATION
    • PLEURAL OR PERICARDIAL PAIN
    • MUSCULOSKELETAL PAIN
    PROVOCATION CHEST PAIN OTHER THAN CARDIAC CAUSES SHARP OR CATCHING SENSATION EXACERBATED BY COUGH MOVEMENT PAIN ASS WITH SPECIFIC MOVEMENT
  • ISCHEMIC CARDIAC PAIN OR DISCOMFORT
    • GRADUAL ONSET OVER MINUTES DURING EXERTION
    PATTERN OF ONSET MUSCULAR PAIN OCCURS AFTER EXERTION
    • SUDDEN
    • INSTANTANEOUS
    CHEST PAIN PATTERN OF ONSET DISSECTING AORTIC ANEURYSM TENSION PNEUMOTHORAX MASSIVE P E
  • ISCHEMIC CARDIAC PAIN OR DISCOMFORT
    • SWEATING
    • NAUSEA
    • VOMITING
    • BREATHLESSNESS
    • COUGH
    • WHEEZE
    ASSOCIATED FEATURES MASSIVE PULM EMBOLISM AND AORTIC DISSECTION ALSO ACCOMPANIED BY AUTONOMIC DISTURBANCES CLASSIC GI SYMPTOMS OESOPHAGEAL REFLUX OESOPHAGITIS PUD BILIARY DISEASE AUTONOMIC DISTURBANCES
  •  
  • MI
    • CHEST PAIN
    • ANXIETY
    • FEAR OF IMPENDING DEATH
    • BREATHLESSNESS
    • VOMITING
    • COLLAPSE
    • SYNCOPE
    • SILENT
    SEVERE LASTS LONGER THAN ANGINAL PAIN TIGHTNESS HEAVINESS CONSTRICTION IN NECK SYMPTOMS
  • MYOCARDIAL INFARCTION SIGNS
    • SIGNS OF SYMPATHETIC ACTIVATION
          • PALLOR
          • SWEATING
          • TACHYCARDIA
    • SIGNS OF VAGAL STIMULATION
          • VOMITING
          • BRADYCARDIA
  • MYOCARDIAL INFARCTION SIGNS
    • SIGNS OF IMPAIRED MYOCARDIAL FUNCTION
      • HYPOTENSION
      • OLIGURIA
      • COLD PERIPHERIES
      • NARROW PULSE PRESSURE
      • RAISED JVP
      • S3
      • QUIET S1
      • DIFFUSE APICAL IMPULSE
      • LUNG CREPTS
      • SIGNS OF TISSUE DAMAGE-------FEVER
      • SIGNS OF COMPLICATIONS----MR,,,,,,,PERICARDITIS
  • MI INVESTIGATIONS
    • ECG HELPFUL
    • DIFFICULT INTERPRETATION IN PREVIOUS MI PATIENTS AND OLD BBB
    • RARELY NORMAL ECG
    • IN 1/3 OF MI CASES INITIAL CHANGES MAY NOT BE DIAGNOSTIC
    • EARLIEST CHANGE ST ELEVATION
    • LATER R WAVE SIZE DIMINUTION
    • Q WAVES IN TRANSMURAL MI
    • T WAVE INVERSION
    • CHEK AREA OF INFARCTION
  • MI INVESTIGATIONS PLASMA BIOCHEMICAL MARKERS
    • CK-MB
    • TROPONIN T & I
  • MI INVESTIGATIONS
    • FBC LEUCOCYTOSIS ON 1 ST . DAY
    • ESR RAISED
    • CRP ELEVATED
    • CXR PUMONARY EDEMA,,,CARDIOMEGALY
    • ECHO
  • Clinical Spectrum of Acute Coronary Syndromes None Positive Positive ECG early ST-segment depression and/or T-wave inversion ST-segment elevation ECG late No Q No Q Q develops Stable angina Unstable angina Non-STE MI STE MI Antman EM. In: Braunwald E, ed. Heart Disease: A Textbook in Cardiovascular Medicine , 5th ed. Philadelphia, Pa: WB Saunders; 1997. ST-segment depression and/or T-wave inversion Evidence of necrosis
  • Acute Coronary Syndromes
    • Similar pathophysiology
    • Similar presentation and early management rules
    • STEMI requires evaluation for acute reperfusion intervention
    • Unstable Angina
    • Non-ST-Segment Elevation MI (NSTEMI)
    • ST-Segment Elevation MI (STEMI)
  • Diagnosis of Acute MI STEMI / NSTEMI
    • At least 2 of the following
        • Ischemic symptoms
        • Diagnostic ECG changes
        • Serum cardiac marker elevations
  • Diagnosis of Unstable Angina
    • Patients with typical angina - An episode of angina
        • Increased in severity or duration
        • Has onset at rest or at a low level of exertion
        • Unrelieved by the amount of nitroglycerin or rest that had previously relieved the pain
    • Patients not known to have typical angina
        • First episode with usual activity or at rest within the previous two weeks
        • Prolonged pain at rest
  • ACS Clinical Presentation
    • Substernal chest pain or pressure (>20-30 min)
    • Localization or radiation to arms, back, throat, jaw
    • Accompanying features
      • Dyspnea
      • Nausea/vomiting
      • Diaphoresis
      • Weakness
    • Atypical: syncope, CVA, DKA
    • Unstable Angina
    • STEMI
    NSTEMI
      • Non occlusive
      • thrombus
      • Non specific
      • ECG
      • Normal cardiac
      • enzymes
      • Occluding thrombus
      • sufficient to cause
      • tissue damage & mild
      • myocardial necrosis
      • ST depression +/-
      • T wave inversion on
      • ECG
      • Elevated cardiac
      • enzymes
      • Complete thrombus
      • occlusion
      • ST elevations on
      • ECG or new LBBB
      • Elevated cardiac
      • enzymes
      • More severe
      • symptoms
  • ECG assessment ST Elevation or new LBBB STEMI Non-specific ECG Unstable Angina ST Depression or dynamic T wave inversions NSTEMI
  • Normal or non-diagnostic EKG
  • ST Depression or Dynamic T wave Inversions
  • ST-Segment Elevation MI
  • New LBBB QRS > 0.12 sec L Axis deviation Prominent R wave V1-V3 Prominent S wave 1, aVL, V5-V6 with t-wave inversion
  • Cardiac markers
    • Troponin ( T, I)
      • Very specific and more sensitive than CK
      • Rises 4-8 hours after injury
      • May remain elevated for up to two weeks
      • Can provide prognostic information
      • Troponin T may be elevated with renal dz, poly/dermatomyositis
    • CK-MB isoenzyme
      • Rises 4-6 hours after injury and peaks at 24 hours
      • Remains elevated 36-48 hours
      • Positive if CK/MB > 5% of total CK and 2 times normal
      • Elevation can be predictive of mortality
      • False positives with exercise, trauma, muscle dz, DM, PE
  • AORTIC DISSECTION
    • A BREACH IN INTEGRITY OF AORTIC WALL
    • ARTERIAL BLOOD BURSTS INTO MEDIA OF AORTA
    • MEDIA SPLITS IN TWO LAYERS.
    • FALSE LUMEN ALONGSIDE A TRUE LUMEN.
    • DOUBLE-BARRELLED OR BILUMINAL AORTA.
  •  
  • AORTIC DISSECTION PREDISPOSING FACTORS
    • HTN
    • AORTIC ATHEROSCLEROSIS
    • NON-SPECIFIC AORTIC ANEURYSM
    • AORTIC COARCTATION
    • COLLAGEN DISORDERS MARFANS SYND,,,E D SYNDROME
    • FIBROMUSCULAR DYSPLASIA
    • PREVIOUS AORTIC SURGERY CABG AV REPLACEMENT
    • PREGNANCY(3 RD , TRIMESTER)
    • TRAUMA
    • IATROGENIC
  • AORTIC DISSECTION CLINICAL FEATURES
    • TEARING PAIN
    • ABRUPT ONST
    • COLLAPSE
    • MARFAN`S SYNDROME
    • PT APPEARS TO BE IN SHOCK
    • BP---NORMAL OR RAISED
    • AC AR MAY DEVELOP
    • ASYMMETRY OF PULSES
    • MI
    • PARAPLEGIA(SPINAL)
    • ACUTE ABDOMEN(MESENTERIC CAELIAC)
    • RENAL FAILURE
    • ACUTE LIMB ISCHEMIA(LEGS)
  • TENSION PNEUMOTHORAX
  • PNEUMOTHORAX
    • PRESENCE OF AIR IN PLEURAL SPACE
    • SPONTANEOUS PRIMARY SECONDARY
    • TRAUMATIC IATROGENIC NON-IATROGENIC
  • PNEUMOTHORAX CLINICAL FEATURES
    • SUDDEN-ONSET UNILAT. CHEST PAIN
    • BREATHLESSNESS
    • ASYMPTOMATIC (NOT TENSION PNEUMOTHORAX)
    • DEC OR ABSENT BREATH SOUNDS (IF PNEUMOTHORAX MORE THAN15%).
    • RESONANT ON PERCUSSION
    • MEDIASTINAL DISPLACEMENT TO OPPOSITE SIDE
    • TACHYCARDIA
    • HYPOTENSION
    • CYANOSIS
    • TRACHEAL DISPLACEMENT
  • TENSION PNEUMOTHORAX DIAGNOSIS
    • CLINICAL
    • CXR
  •  
  • PULMONARY EMBOLISM
    • RISK FACTORS FOR THROMBOEMBOLISM
    • CLINICAL FEATURES DEPEND ON SIZE
    • FAINTNESS OR COLLAPSE
    • CENTRAL CHEST PAIN
    • APPREHENSION
    • SEVERE DYSPNOEA
    • PLEURITIC PAIN
    • HAEMOPTYSIS
  • PULMONARY EMBOLISM SIGNS
    • MAJOR CIRCULATORY COLLAPSE TACHYCARDIA HYPOTENSION INC JVP RT.VENTRICULAR GALLOP RHYTHM SPLIT P2 SEVERE CYANOSIS DEC URINARY OUTPUT.
  • PULMONARY EMBOLISM INVESTIGATIONS
    • CXR USUALLY NORMAL PULM;OPACITIES WEDGE-SHAPED OPACITY HORIZONTAL LINEAR OPACITIES PLEURL EFFUSION OLIGAEMIC LUNG FIELDS ENLARGED PULMONARY ARTERY ELEVATED DIAPHRAGM
  • PULMONARY EMBOLISM INVESTIGATIONS
        • ECG S1 Q3 T3 RBBB SINUS TACHY RV HYPERTROPHY
  • PULMONARY EMBOLISM INVESTIGATIONS ABGs
    • MAY BE NORMAL
    • OR
    • DEC;PaO2 DEC;PaCO2 METABOLIC ACIDOSIS
  • PULM; EMBOLISM INVESTIGATIONS
    • D-DIMER
    • VENTILATION-PERFUSION SCANNING
    • CT PULMONARY ANGIOGRAPHY
    • MRI
    • COLLOR DOPPLER
    • ECHO
  • PLEURISY
    • ANY DISEASE PROCESS INVOLVING PLEURA AND CAUSING PLEURITIC PAIN
    • COMMON FEATURE OF PULMONARY INFECTION AND INFARCTION
    • MAY OCCUR IN MALIGNANCY
  • PLEURISY
    • PLEURAL PAIN
    • RIB MOVEMENT RESTRICTED
    • PLEURAL RUB
    • H/O RESP ILLNESS
    • CXR
  • TB
  • CONNECTIVE TISSUE DISORDERS CAUSING CHEST PAIN
    • RHEUMATOID ARTHRITIS
    • SLE
    • SS
    • DMS
    • PMS
    • RHEUMATIC FEVER
  • CHEST MALIGNANCIES
  • RUPTURED OESOPHAGUS CAUSES
    • MOST COMMON IATROGENIC (ENDOSCOPIC PERFORATION)
    • MALINANCY
    • CORROSIVE STRICTURES PERFORATION
    • POST RADIOTHERY STRICTURES
    • PERFORATED PEPTIC ULCER
    • SPONTANEOUS OESOPHAGEAL PERFORATION (BOERHAAVE SYNDROME)
  •  
  • RUPTURED OESOPHAGUS CLINICAL FEATURES
    • SEVERE CHEST PAIN
    • SHOCK
    • SUB-CUTANEOUS EMPHYSEMA
    • PLEURAL EFFUSION
    • PNEUMOTHORAX
    • PNEUMOMEDIASTINUM
  • OESOPHAGEAL PAIN
    • CAN MIMIC ANGINAL PAIN
    • MAY GET PRECIPITATED BY EXERCISE
    • MAY BE RELIEVED BY NITRATES
    • RELATION WITH SUPINE POSITION,EATING,DRINKING
    • H/O REFLUX
    • CAN RADIATE TO BACK
  • MYOCARDITIS PERICARDITIS
    • PAIN ---- RETROSTERNAL OR IN THE SHOULDER
    • INTENSITY--- VARIES IN WITH MOVEMENT AND PHASE OF RESPIRATION
    • SHARP --- PAIN MAY CATCH THE PATIENT DURING COUGHING OR INSPIRATION
    • H/O PRODROMAL VIRAL ILLNESS
    • DYSPNEA
    • PERICARDIAL FRICTION RUB
    • FEVER
    • LEUCOCYTOSIS
  • ACUTE MYOCARDITIS
    • INFECTIOUS
    • TOXIN/ DRUG INDUCED
    • IMMUNOLOGIC CAUSES
    VIRAL BACT RICKETTSIAL SPIROCHETAL FUNGAL PARASITIC
  • INFECTIOUS ACUTE MYOCARDITIS
    • OFTEN FOLLOWS URTI
    • CHEST PAIN
    • S/O HEART FAILURE
    • ECG SHOW NON-SPECIFIC ST-T CHANGES CONDUCTION DISTURBANCES VENTRICULAR ECTOPY
    • CXR CARDIOMEGALY
  • PERICARDITIS
    • INFLAMMATORY VIRAL TUBERCULAR BORRELIA BURGDORFERI(LYME DISEASE)
    • UREMIC PERICARDITIS
    • NEOPLASTIC
    • POST MI OR POST CARDIOTOMY DRESSLER`S SYNDROME
    • RADIATION
    • SLE
    • RA
    • DRUG-INDUCED
    • MYXEDEMA
  • PERICARDITIS SYMPTOMS
    • PAIN ---- RETROSTERNAL OR IN THE SHOULDER
    • INTENSITY--- VARIES IN WITH MOVEMENT AND PHASE OF RESPIRATION
    • SHARP --- PAIN MAY CATCH THE PATIENT DURING COUGHING OR INSPIRATION
    • H/O PRODROMAL VIRAL ILLNESS
    • DYSPNEA
    • PERICARDIAL FRICTION RUB
    • FEVER
    • LEUCOCYTOSIS
  • PERICARDITIS ECG
  • PERICARDITIS
    • CXR IN PERICARDITIS
    • SHOWS FLUID COLLECTION
    • MAY BE DRY
    • ECHO ADVISED
  • MITRAL VALVE PROLAPSE
  • MITRAL VALVE PROLAPSE
    • SHARP LEFT SIDED CHEST PAIN
    • DYSPNEA
    • FATIGUE
    • PALPITATION
    • FEMALES
    • THIN
    • CHEST WALL DEFORMITIES
    • MID-SYSTOLIC CLICKS
    • ECHO
    • CARDIAC CATH
  • MUSCULOSKELETAL CHEST PAIN
    • VARY WITH POSTURE
    • VARY WITH POSITION
    • LOCAL TENDERNESS
    • ARTHRITIS
    • COSTOCONDRITIS
    • INTERCOSTAL MUSCLE INJURY
    • COXSACKIE VIRAL INFECTION
    • MINOR SOFT TISSUE INJURIES
  • OSTEOARTHRITIS
    • Localized DIS.
    • KNEE OR HIP INVOLVEMEMENT IS COMMON
    • PAIN ON MOVEMENT
    • CREPITUS
    • WORSE AT END OF DAY
    • TENDER JT.
  • TEITZE`S SYNDROME IDIOPATHIC COSTOCONDRITIS
    • LOCALIZED PAIN/TENDERNESS AT COSTOCONDRAL JUNCTION
    • ENHANCED BY EMOTION,COUGHING,SNEEZING
    • 2nd.RIB MOST AFFECTED
  • PROLAPSED DISC
  • HERPES ZOSTER
  • THANK YOU