Chest Pain-case 2

4,600 views

Published on

Common clinical case scenario @ Emergency department about chest pain

Published in: Health & Medicine

Chest Pain-case 2

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

×