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Approach To Patient With Chset Pain
 

Approach To Patient With Chset Pain

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'APPROACH TO PATIENT WITH CHSET PAIN

'APPROACH TO PATIENT WITH CHSET PAIN

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    Approach To Patient With Chset Pain Approach To Patient With Chset Pain Presentation Transcript

    • Approach to a patient with chest pain presenting in primary care setting DR Ihab Suliman MBBS,MRCP,Diplomate certification Board of Nuclear Cardiology(USA)
    • Chest Pain
      • Common presentation.
      • Trivial to life-threatening causes.
      • Key to diagnosis is history NOT INVESTIGATIONS.
      • Negative baseline investigations DO NOT ruleout serious conditions
    • Life-threatening Causes of Chest Pain
      • Myocardial infarction(ACS).
      • Thoracic aortic dissection.
      • Pulmonary embolus.
      • Tension pneumothorax.
      • Oesophageal rupture.
    • 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.
    • 26 yr old thin man with sudden onset of severe L sided sharp chest pain ,tachypnoeic.
      • Right Pneumothorax
    • 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 vomited twice .
    • 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 vomited twice .
      • Anterior (extensive) Myocardial infarction.
      • Why ?
      • Male 65 years.
      • H/O DM+HTN( remember INTERHEART study)
      • Crushing chest pain.
      • Associated sweaty,clammy,vomiting.
    • 70 years old male with long history of untreated HTN,nonsmoker came complaining of chest pain migrated to interscapular region & became severe(tearing),SBP 200,ECG mild inferior changes
      • Most likely diagnosis is
      • ? AMI
      • ?PE
      • ?Esophagear Rupture
      • ?Aortic Dissection
    •  
      • Aortic Dissection
      • Severe, sharp, “tearing” posterior chest pain or back pain (occurs in 74-90% of pts)
      • Pain may be associated with syncope, CVA, MI, or CHF
        • Painless dissection relatively uncommon 15%
      • Chest pain is more common with Type A dissections
      • Back or abdominal pain is more common with Type B dissections
      • Physical Examination
      • Pulse deficit
        • Weak or absent carotid, brachial, or femoral pulses
        • these patients have a higher rate of mortality
      • Acute Aortic Insufficiency
        • Diastolic decrescendo murmur
        • Best heard along the right sternal border
    • TEE of Aortic Dissection & CT aorta
    • 40 years old male finished cardiac evaluation last week for insurance (every thing is normal) .ate a heavy meal with friends (celebrating).followed by severe vomiting then chest pain.vomitus contains streaks of fresh blood.
      • Likely diagnosis
      • ?ACS
      • ?PE
      • ?Aortic Dissection
      • Esophageal submucosal tear(mallory weiss syndrome).
    • A 26 year old woman presented 1 week post delivery of her first baby. She has sharp L sided chest pain and she is short of breath.
      • Pulmonary Embolism
      • Why ?
      • Young female
      • Pegnancy hypercoagulable state
      • Occurrence one week post partum
    • 50 years old female with chronic renal failure,chest pain & dizziness she is hypertensive on lisinopril
      • Hyperkalemia,tall tented T-wave & bradycardia.
      • Why ?
      • Chronic renal failure
      • Patient on lisinopril
    • 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 HTN,nonsmoker,lipid profile LDL 2.0 MMMOL/ L
      • Acute Pericarditis
    • 26 Old army officer had flu last week,felt chest pain while driving his car,pain increased by deep breath,ECG after 5 days .
      • Resolved Pericardtis.
    •  
    •  
      • Diagnostic limitations
      • History:
      • 25% have ‘atypical’ histories
      • ECG:
      • 55% of pts with AMI have a normal 1 ST 12-lead ECG
      • Convential Cardiac Markers :
      • Normal for the first 3- 4 hours
      • Take home points
      • History 90%
      • ECG: if ST elevated act fast
      • Risk factor reduction
      • Never ignore chest pain