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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 <ul><li>5 Million emergency department visits </li></ul><ul><li>2 million hospitalizations annually with cost o...
Goals <ul><li>Rapid recognition of management of true ACS </li></ul><ul><li>Recognition of other life-threatening causes o...
Chest Pain Diagnosis <ul><li>Clinical diagnosis </li></ul><ul><li>Diagnosis using computer algorithms </li></ul><ul><li>Ch...
CHEST PAIN (1429)   <ul><li>TOTAL PATIENTS=544 </li></ul><ul><li>IHD=  518 </li></ul><ul><li>CCF=  19 </li></ul><ul><li>MI...
PAIN JUST A CURSE OR A MERCY OF GOD
PAIN? <ul><li>UNIVERSALLY UNDERSTOOD AS “DISEASE SIGNAL” </li></ul><ul><li>MOST COMMON SYMPTOM THAT BRINGS A PATIENT TO A ...
ITS BOTH  SENSATION  AND  EMOTION <ul><li>ACCOMPANIED BY ANXIETY </li></ul><ul><li>ACCAMPANIED BY URGE TO ESCAPE OR TERMIN...
PAIN HOW DESCRIBED? <ul><li>STABBING </li></ul><ul><li>BURNING </li></ul><ul><li>TWISTING </li></ul><ul><li>TEARING </li><...
ACUTE PAIN <ul><li>BEHAVIORAL AROUSAL </li></ul><ul><li>STRESS RESPONSE </li></ul><ul><li>LOCAL MUSCLE CONTRACTION </li></...
PAIN IN THE CHEST BUT ORIGIN?? <ul><li>HEART </li></ul><ul><li>LUNGS </li></ul><ul><li>OESOPHAGUS </li></ul><ul><li>MUSCUL...
CHEST PAIN CLASSIFICATION FROM CLINICAL VIEW POINT: RECURRENT OFTEN PAROXYSMAL MILD OR MODERATE ANGINA MUSCULOSKELETAL PAI...
WHAT LIES IN THE CHEST? <ul><li>SKIN </li></ul><ul><li>MUSCLES </li></ul><ul><li>BONES </li></ul><ul><li>JOINTS </li></ul>...
 
 
CHEST PAIN ASSESSMENT <ul><li>HISTORY  </li></ul><ul><li>EXAMINATION </li></ul><ul><li>ECG </li></ul><ul><li>CARDIAC ENZYM...
INITIAL APPROACH <ul><li>Assume the worst! </li></ul><ul><li>100% Oxygen </li></ul><ul><li>IV access </li></ul><ul><li>Mon...
TIME IS VITAL
CHEST PAIN <ul><li>COMMON PRESENTATION TO A&E </li></ul><ul><li>TRIVIAL TO LIFE-THREATENING CAUSES </li></ul><ul><li>KEY T...
<ul><li>HEART ATTACK </li></ul><ul><li>ANSWER  IS  NO …… </li></ul><ul><li>RELAX </li></ul><ul><li>IS IT ENOUGH TO RULE OU...
Life Threatening Chest Pain in the Emergency Department <ul><li>•   Myocardial Infarction  </li></ul><ul><li>USA </li></ul...
COMMON CAUSES OF CHEST PAIN <ul><li>ANXIETY </li></ul><ul><li>CARDIAC </li></ul><ul><li>AORTIC </li></ul><ul><li>OESOPHAGE...
CARDIAC OR NON-CARDIAC PAIN?
Chest Pain: History <ul><li>P: pattern (temporal sequence) </li></ul><ul><li>A: associated features  </li></ul><ul><ul><li...
CHEST PAIN ASSESSMENT <ul><li>History  VITALLY IMPORTANT </li></ul><ul><li>PAIN  </li></ul><ul><li>NATURE </li></ul><ul><l...
Chest Pain: Physical Exam <ul><li>Vital signs and general appearance </li></ul><ul><li>Carotids and JVP </li></ul><ul><li>...
CHEST PAIN ASSESSMENT <ul><li>Examination </li></ul><ul><li>General Examination   </li></ul><ul><li>( sweaty clammy pale c...
Chest Pain: Location Myocardial ischemia Pericarditis Pleurisy, Sub-diap abscess Myocardial ischemia Cervical spine Thorac...
ISCHEMIC CARDIAC PAIN NON-CARDIAC PAIN V/S LOCATION CENTRAL, DIFFUSE PERIPHERAL LOCALIZED RADIATION JAW/NECK/SHOULDER/ OCC...
MYOCARDIAL ISCHEMIA(ANGINA) MI MYOCARDITIS PERICARDITIS MVP AORTIC DISSECTION AORTIC ANEURYSM ESOPHAGITIS ESOPH SPASM MW S...
ANXIETY <ul><li>ANXIOUS THOUGHTS </li></ul><ul><li>AVOIDANCE BEHAVIOUR </li></ul><ul><li>SOMATIC SYMPTOMS </li></ul><ul><l...
ISCHEMIC CARDIAC PAIN ORIGIN? SITE OF ORIGIN OF PAIN CENTRAL
ISCHEMIC CARDIAC PAIN <ul><li>MAY RADIATE TO NECK </li></ul><ul><li>JAW </li></ul><ul><li>UPPER OR LOWER ARM </li></ul><ul...
 
ISCHEMIC CARDIAC PAIN <ul><li>PLEURAL PROBLEMS </li></ul><ul><li>LUNG PROBLEMS </li></ul><ul><li>MUSCULOSKELETAL  </li></u...
ISCHEMIC CARDIAC  PAIN OR DISCOMFORT <ul><li>TYPICALLY DULL </li></ul><ul><li>CONSTRICTING </li></ul><ul><li>CHOKING </li>...
ISCHEMIC CARDIAC  PAIN OR DISCOMFORT <ul><li>EXERTION </li></ul><ul><li>EMOTIONS </li></ul><ul><li>LARGE MEALS </li></ul><...
<ul><li>PLEURAL OR PERICARDIAL PAIN </li></ul><ul><li>MUSCULOSKELETAL PAIN </li></ul>PROVOCATION CHEST PAIN OTHER THAN CAR...
ISCHEMIC CARDIAC  PAIN OR DISCOMFORT <ul><li>GRADUAL ONSET OVER MINUTES DURING EXERTION </li></ul>PATTERN OF ONSET MUSCULA...
<ul><li>SUDDEN </li></ul><ul><li>INSTANTANEOUS </li></ul>CHEST PAIN PATTERN OF ONSET DISSECTING AORTIC ANEURYSM TENSION PN...
ISCHEMIC CARDIAC  PAIN OR DISCOMFORT <ul><li>SWEATING </li></ul><ul><li>NAUSEA </li></ul><ul><li>VOMITING </li></ul><ul><l...
 
MI <ul><li>CHEST PAIN  </li></ul><ul><li>ANXIETY </li></ul><ul><li>FEAR OF IMPENDING DEATH </li></ul><ul><li>BREATHLESSNES...
MYOCARDIAL INFARCTION SIGNS <ul><li>SIGNS OF SYMPATHETIC ACTIVATION </li></ul><ul><ul><ul><ul><li>PALLOR </li></ul></ul></...
MYOCARDIAL INFARCTION SIGNS <ul><li>SIGNS OF IMPAIRED MYOCARDIAL FUNCTION </li></ul><ul><ul><li>HYPOTENSION </li></ul></ul...
MI INVESTIGATIONS <ul><li>ECG HELPFUL  </li></ul><ul><li>DIFFICULT INTERPRETATION IN PREVIOUS MI PATIENTS AND OLD BBB </li...
MI INVESTIGATIONS  PLASMA BIOCHEMICAL MARKERS <ul><li>CK-MB </li></ul><ul><li>TROPONIN T & I </li></ul>
MI INVESTIGATIONS <ul><li>FBC  LEUCOCYTOSIS ON 1 ST . DAY </li></ul><ul><li>ESR   RAISED  </li></ul><ul><li>CRP   ELEVATED...
Clinical Spectrum of Acute Coronary Syndromes None Positive Positive ECG early ST-segment  depression and/or T-wave invers...
Acute Coronary Syndromes <ul><li>Similar pathophysiology </li></ul><ul><li>Similar presentation and early management rules...
Diagnosis of Acute MI  STEMI / NSTEMI <ul><li>At least 2 of the following </li></ul><ul><ul><ul><li>Ischemic symptoms </li...
Diagnosis of Unstable Angina <ul><li>Patients with typical angina - An episode of angina  </li></ul><ul><ul><ul><li>Increa...
ACS Clinical Presentation <ul><li>Substernal chest pain or pressure (>20-30 min) </li></ul><ul><li>Localization or radiati...
<ul><li>Unstable Angina </li></ul><ul><li>STEMI </li></ul>NSTEMI <ul><ul><li>Non occlusive  </li></ul></ul><ul><ul><li>thr...
ECG assessment ST Elevation or new LBBB STEMI Non-specific ECG Unstable Angina ST Depression or dynamic T wave inversions ...
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 <ul><li>Troponin ( T, I) </li></ul><ul><ul><li>Very specific and more sensitive than CK </li></ul></ul><ul...
AORTIC DISSECTION <ul><li>A BREACH IN INTEGRITY OF AORTIC WALL </li></ul><ul><li>ARTERIAL BLOOD BURSTS INTO MEDIA OF AORTA...
 
AORTIC DISSECTION PREDISPOSING FACTORS <ul><li>HTN </li></ul><ul><li>AORTIC ATHEROSCLEROSIS </li></ul><ul><li>NON-SPECIFIC...
AORTIC DISSECTION CLINICAL FEATURES <ul><li>TEARING PAIN </li></ul><ul><li>ABRUPT ONST </li></ul><ul><li>COLLAPSE </li></u...
TENSION PNEUMOTHORAX
PNEUMOTHORAX <ul><li>PRESENCE OF AIR IN PLEURAL SPACE </li></ul><ul><li>SPONTANEOUS PRIMARY SECONDARY </li></ul><ul><li>TR...
PNEUMOTHORAX CLINICAL FEATURES <ul><li>SUDDEN-ONSET UNILAT. CHEST PAIN </li></ul><ul><li>BREATHLESSNESS </li></ul><ul><li>...
TENSION PNEUMOTHORAX DIAGNOSIS <ul><li>CLINICAL </li></ul><ul><li>CXR </li></ul>
 
PULMONARY EMBOLISM <ul><li>RISK FACTORS FOR THROMBOEMBOLISM </li></ul><ul><li>CLINICAL FEATURES DEPEND ON SIZE  </li></ul>...
PULMONARY EMBOLISM SIGNS <ul><li>MAJOR CIRCULATORY COLLAPSE TACHYCARDIA HYPOTENSION INC JVP RT.VENTRICULAR GALLOP RHYTHM S...
PULMONARY EMBOLISM INVESTIGATIONS <ul><li>CXR USUALLY NORMAL PULM;OPACITIES WEDGE-SHAPED OPACITY HORIZONTAL LINEAR OPACITI...
PULMONARY EMBOLISM INVESTIGATIONS <ul><ul><ul><li>ECG S1 Q3 T3 RBBB SINUS TACHY RV HYPERTROPHY </li></ul></ul></ul>
PULMONARY EMBOLISM INVESTIGATIONS  ABGs <ul><li>MAY BE NORMAL </li></ul><ul><li>OR </li></ul><ul><li>DEC;PaO2 DEC;PaCO2 ME...
PULM; EMBOLISM INVESTIGATIONS <ul><li>D-DIMER </li></ul><ul><li>VENTILATION-PERFUSION SCANNING </li></ul><ul><li>CT PULMON...
PLEURISY <ul><li>ANY DISEASE PROCESS INVOLVING PLEURA AND CAUSING PLEURITIC PAIN </li></ul><ul><li>COMMON FEATURE OF PULMO...
PLEURISY <ul><li>PLEURAL PAIN </li></ul><ul><li>RIB MOVEMENT RESTRICTED </li></ul><ul><li>PLEURAL RUB </li></ul><ul><li>H/...
TB
CONNECTIVE TISSUE DISORDERS CAUSING CHEST PAIN <ul><li>RHEUMATOID ARTHRITIS </li></ul><ul><li>SLE </li></ul><ul><li>SS </l...
CHEST MALIGNANCIES
RUPTURED OESOPHAGUS CAUSES <ul><li>MOST COMMON IATROGENIC (ENDOSCOPIC PERFORATION) </li></ul><ul><li>MALINANCY </li></ul><...
 
RUPTURED OESOPHAGUS CLINICAL FEATURES <ul><li>SEVERE CHEST PAIN </li></ul><ul><li>SHOCK </li></ul><ul><li>SUB-CUTANEOUS EM...
OESOPHAGEAL PAIN <ul><li>CAN MIMIC ANGINAL PAIN </li></ul><ul><li>MAY GET PRECIPITATED BY EXERCISE </li></ul><ul><li>MAY B...
MYOCARDITIS PERICARDITIS <ul><li>PAIN  ---- RETROSTERNAL OR  IN THE SHOULDER </li></ul><ul><li>INTENSITY---  VARIES  IN WI...
ACUTE MYOCARDITIS <ul><li>INFECTIOUS </li></ul><ul><li>TOXIN/ DRUG INDUCED </li></ul><ul><li>IMMUNOLOGIC CAUSES </li></ul>...
INFECTIOUS ACUTE MYOCARDITIS <ul><li>OFTEN FOLLOWS URTI </li></ul><ul><li>CHEST PAIN </li></ul><ul><li>S/O HEART FAILURE <...
PERICARDITIS <ul><li>INFLAMMATORY  VIRAL  TUBERCULAR  BORRELIA BURGDORFERI(LYME DISEASE) </li></ul><ul><li>UREMIC PERICARD...
PERICARDITIS SYMPTOMS <ul><li>PAIN  ---- RETROSTERNAL OR  IN THE SHOULDER </li></ul><ul><li>INTENSITY---  VARIES  IN WITH ...
PERICARDITIS ECG
PERICARDITIS <ul><li>CXR IN PERICARDITIS </li></ul><ul><li>SHOWS FLUID COLLECTION </li></ul><ul><li>MAY BE DRY </li></ul><...
MITRAL VALVE PROLAPSE
MITRAL VALVE PROLAPSE <ul><li>SHARP LEFT SIDED CHEST PAIN </li></ul><ul><li>DYSPNEA </li></ul><ul><li>FATIGUE </li></ul><u...
MUSCULOSKELETAL CHEST PAIN <ul><li>VARY WITH POSTURE </li></ul><ul><li>VARY WITH POSITION </li></ul><ul><li>LOCAL TENDERNE...
OSTEOARTHRITIS <ul><li>Localized DIS. </li></ul><ul><li>KNEE OR HIP INVOLVEMEMENT IS COMMON </li></ul><ul><li>PAIN ON MOVE...
TEITZE`S SYNDROME IDIOPATHIC COSTOCONDRITIS <ul><li>LOCALIZED PAIN/TENDERNESS  AT COSTOCONDRAL JUNCTION </li></ul><ul><li>...
PROLAPSED DISC
HERPES ZOSTER
THANK YOU
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Differential diagnosis of chest pain by dr farooq on 29 02-30 h.

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

  1. 1. WELCOME TO CME CFH
  2. 2. IN THE NAME OF ALLAH THE MOST GRACIOUS,THE MOST MERCIFUL
  3. 4. DIFFERENTIAL DIAGNOSIS OF CHEST PAIN DR.MUHAMMAD FAROOQUE MB BS DTCD
  4. 5. Chest Pain <ul><li>5 Million emergency department visits </li></ul><ul><li>2 million hospitalizations annually with cost of more than $8 billion </li></ul><ul><li>Cardiac etiology found in less than one third </li></ul><ul><li>2% of patients with acute MI are unrecognized and discharged from the ED </li></ul>
  5. 6. Goals <ul><li>Rapid recognition of management of true ACS </li></ul><ul><li>Recognition of other life-threatening causes of chest pain </li></ul><ul><li>Minimize cost and hospitalization in patients with chest pain of benign etiology. </li></ul>
  6. 7. Chest Pain Diagnosis <ul><li>Clinical diagnosis </li></ul><ul><li>Diagnosis using computer algorithms </li></ul><ul><li>Chest pain centers </li></ul>
  7. 8. CHEST PAIN (1429) <ul><li>TOTAL PATIENTS=544 </li></ul><ul><li>IHD= 518 </li></ul><ul><li>CCF= 19 </li></ul><ul><li>MI DIAGNOSED ON ECG =7 </li></ul>COURTESY: HAMAD RASHID AL-MONAJAM
  8. 9. PAIN JUST A CURSE OR A MERCY OF GOD
  9. 10. PAIN? <ul><li>UNIVERSALLY UNDERSTOOD AS “DISEASE SIGNAL” </li></ul><ul><li>MOST COMMON SYMPTOM THAT BRINGS A PATIENT TO A PHYSICIAN`S ATTENTION. </li></ul><ul><li>AN UNPLEASANT SENSATION LOCALIZED TO A PART OF THE BODY </li></ul><ul><li>ITS BOTH SENSATION AND EMOTION </li></ul>
  10. 11. ITS BOTH SENSATION AND EMOTION <ul><li>ACCOMPANIED BY ANXIETY </li></ul><ul><li>ACCAMPANIED BY URGE TO ESCAPE OR TERMINATE THE FEELING </li></ul>DUALITY OF PAIN PAIN
  11. 12. PAIN HOW DESCRIBED? <ul><li>STABBING </li></ul><ul><li>BURNING </li></ul><ul><li>TWISTING </li></ul><ul><li>TEARING </li></ul><ul><li>SQUEEZING </li></ul><ul><li>TERRIFYING </li></ul><ul><li>NAUSEATING </li></ul><ul><li>SICKENING </li></ul>PENETRATING OR TISSUE-DESTRUCTIVE PROCESS BODILY OR EMOTIONAL REACTION
  12. 13. ACUTE PAIN <ul><li>BEHAVIORAL AROUSAL </li></ul><ul><li>STRESS RESPONSE </li></ul><ul><li>LOCAL MUSCLE CONTRACTION </li></ul>INC BP INC HR INC PUPIL DIAMETER INC PLASMA CORTISOL LEVEL ASSOCIATED WITH
  13. 14. PAIN IN THE CHEST BUT ORIGIN?? <ul><li>HEART </li></ul><ul><li>LUNGS </li></ul><ul><li>OESOPHAGUS </li></ul><ul><li>MUSCULOSKELETAL STRUCTURES OF THORAX NECK,OR SHOULDER </li></ul><ul><li>ABDOMEN </li></ul><ul><li>ANXIETY MANIFESTATION </li></ul>
  14. 15. 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
  15. 16. WHAT LIES IN THE CHEST? <ul><li>SKIN </li></ul><ul><li>MUSCLES </li></ul><ul><li>BONES </li></ul><ul><li>JOINTS </li></ul><ul><li>HEART AND VESSELS </li></ul><ul><li>LUNGS AND AIRWAYS </li></ul><ul><li>OESOPHAGUS </li></ul><ul><li>NERVES </li></ul>
  16. 19. CHEST PAIN ASSESSMENT <ul><li>HISTORY </li></ul><ul><li>EXAMINATION </li></ul><ul><li>ECG </li></ul><ul><li>CARDIAC ENZYMES </li></ul><ul><li>CXR </li></ul><ul><li>OTHERS </li></ul>
  17. 20. INITIAL APPROACH <ul><li>Assume the worst! </li></ul><ul><li>100% Oxygen </li></ul><ul><li>IV access </li></ul><ul><li>Monitoring </li></ul><ul><li>ECG quickly </li></ul><ul><li>Done in tandem with history taking </li></ul>
  18. 21. TIME IS VITAL
  19. 22. CHEST PAIN <ul><li>COMMON PRESENTATION TO A&E </li></ul><ul><li>TRIVIAL TO LIFE-THREATENING CAUSES </li></ul><ul><li>KEY TO DIAGNOSIS IS HISTORY </li></ul><ul><li>NEGATIVE BASELINE INVESTIGATIONS DO NOT RULE OUT SERIOUS CONDITIONS </li></ul>
  20. 23. <ul><li>HEART ATTACK </li></ul><ul><li>ANSWER IS NO …… </li></ul><ul><li>RELAX </li></ul><ul><li>IS IT ENOUGH TO RULE OUT HEART ATTACK? </li></ul>LIFE THREATENING CHEST PAIN IN THE EMERGENCY DEPARTMENT
  21. 24. Life Threatening Chest Pain in the Emergency Department <ul><li>• Myocardial Infarction </li></ul><ul><li>USA </li></ul><ul><li>• Aortic Dissection </li></ul><ul><li>• Tension Pneumothorax </li></ul><ul><li>• Pulmonary Embolus </li></ul><ul><li>• Ruptured Esophagus/Perforated Ulcer </li></ul>
  22. 25. COMMON CAUSES OF CHEST PAIN <ul><li>ANXIETY </li></ul><ul><li>CARDIAC </li></ul><ul><li>AORTIC </li></ul><ul><li>OESOPHAGEAL </li></ul><ul><li>LUNGS/PLEURA </li></ul><ul><li>MUSCULOSKELETAL </li></ul><ul><li>NEUROLOGICAL </li></ul>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
  23. 26. CARDIAC OR NON-CARDIAC PAIN?
  24. 27. Chest Pain: History <ul><li>P: pattern (temporal sequence) </li></ul><ul><li>A: associated features </li></ul><ul><ul><li>SOB, N/V, diaphoresis </li></ul></ul><ul><ul><li>fever, cough, chills </li></ul></ul><ul><ul><li>abdominal pain </li></ul></ul><ul><li>I: initiation and improvement </li></ul><ul><li>N: nature (quality) </li></ul>
  25. 28. CHEST PAIN ASSESSMENT <ul><li>History VITALLY IMPORTANT </li></ul><ul><li>PAIN </li></ul><ul><li>NATURE </li></ul><ul><li>SITE </li></ul><ul><li>SEVERITY </li></ul><ul><li>RADIATION </li></ul><ul><li>ONSET </li></ul><ul><li>EXAC/RELIEVING FACTORS </li></ul><ul><li>ASSOCIATED FEATURES </li></ul><ul><li>DURATION </li></ul><ul><li>PREVIOUS SIMILAR PAINS </li></ul>
  26. 29. Chest Pain: Physical Exam <ul><li>Vital signs and general appearance </li></ul><ul><li>Carotids and JVP </li></ul><ul><li>Lungs </li></ul><ul><li>Cardiac exam </li></ul><ul><li>Thoracic cage </li></ul><ul><li>Abdominal exam </li></ul><ul><li>Periphery (pulses) </li></ul><ul><li>Skin </li></ul>
  27. 30. CHEST PAIN ASSESSMENT <ul><li>Examination </li></ul><ul><li>General Examination </li></ul><ul><li>( sweaty clammy pale cyanosed, anaemic etc pulse BP) </li></ul><ul><li>Cardiovascular /Respiratory examination </li></ul><ul><li>? Failure ( crackles ,oedema, raised JVP) </li></ul><ul><li>Heart Sounds </li></ul><ul><li>- rate , nature ,?quiet ? added heart sounds, ?murmurs </li></ul>
  28. 31. 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
  29. 32. 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
  30. 33. 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
  31. 34. ANXIETY <ul><li>ANXIOUS THOUGHTS </li></ul><ul><li>AVOIDANCE BEHAVIOUR </li></ul><ul><li>SOMATIC SYMPTOMS </li></ul><ul><li>STRESS </li></ul><ul><li>H/O UNPLEASANT INCIDENCE </li></ul><ul><li>HYPERVENTILATION </li></ul><ul><li>BREATHLESSNESS </li></ul><ul><li>PALPITATION </li></ul><ul><li>CHEST PAIN </li></ul><ul><li>HEADACHE </li></ul><ul><li>TINGLING SENSATION </li></ul><ul><li>NAUSEA </li></ul><ul><li>LBM </li></ul><ul><li>URINARY FREQUENCY </li></ul>
  32. 35. ISCHEMIC CARDIAC PAIN ORIGIN? SITE OF ORIGIN OF PAIN CENTRAL
  33. 36. ISCHEMIC CARDIAC PAIN <ul><li>MAY RADIATE TO NECK </li></ul><ul><li>JAW </li></ul><ul><li>UPPER OR LOWER ARM </li></ul><ul><li>BACK </li></ul>RADIATION
  34. 38. ISCHEMIC CARDIAC PAIN <ul><li>PLEURAL PROBLEMS </li></ul><ul><li>LUNG PROBLEMS </li></ul><ul><li>MUSCULOSKELETAL </li></ul><ul><li>ANXIETY </li></ul>PAIN RADIATION OTHER POSSIBILITIES
  35. 39. ISCHEMIC CARDIAC PAIN OR DISCOMFORT <ul><li>TYPICALLY DULL </li></ul><ul><li>CONSTRICTING </li></ul><ul><li>CHOKING </li></ul><ul><li>HEAVY </li></ul><ul><li>USUALLY DESCRIBED BY PATIENTS AS---SQUEEZING— CRUSHING---- BURNING------- ACHING BUT NOT SHARP BUT NOT STABBING BUT NOT PRICKING BUT NOT KNIFE-LIKE </li></ul><ul><li>SENSATION CAN BE DESCRIBED AS BREATHLESSNESS </li></ul>CHARACTER OF PAIN
  36. 40. ISCHEMIC CARDIAC PAIN OR DISCOMFORT <ul><li>EXERTION </li></ul><ul><li>EMOTIONS </li></ul><ul><li>LARGE MEALS </li></ul><ul><li>COLD WIND </li></ul><ul><li>UA AT REST </li></ul><ul><li>LYING DOWN (DECUBITUS ANGINA) </li></ul>PROVOCATION
  37. 41. <ul><li>PLEURAL OR PERICARDIAL PAIN </li></ul><ul><li>MUSCULOSKELETAL PAIN </li></ul>PROVOCATION CHEST PAIN OTHER THAN CARDIAC CAUSES SHARP OR CATCHING SENSATION EXACERBATED BY COUGH MOVEMENT PAIN ASS WITH SPECIFIC MOVEMENT
  38. 42. ISCHEMIC CARDIAC PAIN OR DISCOMFORT <ul><li>GRADUAL ONSET OVER MINUTES DURING EXERTION </li></ul>PATTERN OF ONSET MUSCULAR PAIN OCCURS AFTER EXERTION
  39. 43. <ul><li>SUDDEN </li></ul><ul><li>INSTANTANEOUS </li></ul>CHEST PAIN PATTERN OF ONSET DISSECTING AORTIC ANEURYSM TENSION PNEUMOTHORAX MASSIVE P E
  40. 44. ISCHEMIC CARDIAC PAIN OR DISCOMFORT <ul><li>SWEATING </li></ul><ul><li>NAUSEA </li></ul><ul><li>VOMITING </li></ul><ul><li>BREATHLESSNESS </li></ul><ul><li>COUGH </li></ul><ul><li>WHEEZE </li></ul>ASSOCIATED FEATURES MASSIVE PULM EMBOLISM AND AORTIC DISSECTION ALSO ACCOMPANIED BY AUTONOMIC DISTURBANCES CLASSIC GI SYMPTOMS OESOPHAGEAL REFLUX OESOPHAGITIS PUD BILIARY DISEASE AUTONOMIC DISTURBANCES
  41. 46. MI <ul><li>CHEST PAIN </li></ul><ul><li>ANXIETY </li></ul><ul><li>FEAR OF IMPENDING DEATH </li></ul><ul><li>BREATHLESSNESS </li></ul><ul><li>VOMITING </li></ul><ul><li>COLLAPSE </li></ul><ul><li>SYNCOPE </li></ul><ul><li>SILENT </li></ul>SEVERE LASTS LONGER THAN ANGINAL PAIN TIGHTNESS HEAVINESS CONSTRICTION IN NECK SYMPTOMS
  42. 47. MYOCARDIAL INFARCTION SIGNS <ul><li>SIGNS OF SYMPATHETIC ACTIVATION </li></ul><ul><ul><ul><ul><li>PALLOR </li></ul></ul></ul></ul><ul><ul><ul><ul><li>SWEATING </li></ul></ul></ul></ul><ul><ul><ul><ul><li>TACHYCARDIA </li></ul></ul></ul></ul><ul><li>SIGNS OF VAGAL STIMULATION </li></ul><ul><ul><ul><ul><li>VOMITING </li></ul></ul></ul></ul><ul><ul><ul><ul><li>BRADYCARDIA </li></ul></ul></ul></ul>
  43. 48. MYOCARDIAL INFARCTION SIGNS <ul><li>SIGNS OF IMPAIRED MYOCARDIAL FUNCTION </li></ul><ul><ul><li>HYPOTENSION </li></ul></ul><ul><ul><li>OLIGURIA </li></ul></ul><ul><ul><li>COLD PERIPHERIES </li></ul></ul><ul><ul><li>NARROW PULSE PRESSURE </li></ul></ul><ul><ul><li>RAISED JVP </li></ul></ul><ul><ul><li>S3 </li></ul></ul><ul><ul><li>QUIET S1 </li></ul></ul><ul><ul><li>DIFFUSE APICAL IMPULSE </li></ul></ul><ul><ul><li>LUNG CREPTS </li></ul></ul><ul><ul><li>SIGNS OF TISSUE DAMAGE-------FEVER </li></ul></ul><ul><ul><li>SIGNS OF COMPLICATIONS----MR,,,,,,,PERICARDITIS </li></ul></ul>
  44. 49. MI INVESTIGATIONS <ul><li>ECG HELPFUL </li></ul><ul><li>DIFFICULT INTERPRETATION IN PREVIOUS MI PATIENTS AND OLD BBB </li></ul><ul><li>RARELY NORMAL ECG </li></ul><ul><li>IN 1/3 OF MI CASES INITIAL CHANGES MAY NOT BE DIAGNOSTIC </li></ul><ul><li>EARLIEST CHANGE ST ELEVATION </li></ul><ul><li>LATER R WAVE SIZE DIMINUTION </li></ul><ul><li>Q WAVES IN TRANSMURAL MI </li></ul><ul><li>T WAVE INVERSION </li></ul><ul><li>CHEK AREA OF INFARCTION </li></ul>
  45. 50. MI INVESTIGATIONS PLASMA BIOCHEMICAL MARKERS <ul><li>CK-MB </li></ul><ul><li>TROPONIN T & I </li></ul>
  46. 51. MI INVESTIGATIONS <ul><li>FBC LEUCOCYTOSIS ON 1 ST . DAY </li></ul><ul><li>ESR RAISED </li></ul><ul><li>CRP ELEVATED </li></ul><ul><li>CXR PUMONARY EDEMA,,,CARDIOMEGALY </li></ul><ul><li>ECHO </li></ul>
  47. 52. 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
  48. 53. Acute Coronary Syndromes <ul><li>Similar pathophysiology </li></ul><ul><li>Similar presentation and early management rules </li></ul><ul><li>STEMI requires evaluation for acute reperfusion intervention </li></ul><ul><li>Unstable Angina </li></ul><ul><li>Non-ST-Segment Elevation MI (NSTEMI) </li></ul><ul><li>ST-Segment Elevation MI (STEMI) </li></ul>
  49. 54. Diagnosis of Acute MI STEMI / NSTEMI <ul><li>At least 2 of the following </li></ul><ul><ul><ul><li>Ischemic symptoms </li></ul></ul></ul><ul><ul><ul><li>Diagnostic ECG changes </li></ul></ul></ul><ul><ul><ul><li>Serum cardiac marker elevations </li></ul></ul></ul>
  50. 55. Diagnosis of Unstable Angina <ul><li>Patients with typical angina - An episode of angina </li></ul><ul><ul><ul><li>Increased in severity or duration </li></ul></ul></ul><ul><ul><ul><li>Has onset at rest or at a low level of exertion </li></ul></ul></ul><ul><ul><ul><li>Unrelieved by the amount of nitroglycerin or rest that had previously relieved the pain </li></ul></ul></ul><ul><li>Patients not known to have typical angina </li></ul><ul><ul><ul><li>First episode with usual activity or at rest within the previous two weeks </li></ul></ul></ul><ul><ul><ul><li>Prolonged pain at rest </li></ul></ul></ul>
  51. 56. ACS Clinical Presentation <ul><li>Substernal chest pain or pressure (>20-30 min) </li></ul><ul><li>Localization or radiation to arms, back, throat, jaw </li></ul><ul><li>Accompanying features </li></ul><ul><ul><li>Dyspnea </li></ul></ul><ul><ul><li>Nausea/vomiting </li></ul></ul><ul><ul><li>Diaphoresis </li></ul></ul><ul><ul><li>Weakness </li></ul></ul><ul><li>Atypical: syncope, CVA, DKA </li></ul>
  52. 57. <ul><li>Unstable Angina </li></ul><ul><li>STEMI </li></ul>NSTEMI <ul><ul><li>Non occlusive </li></ul></ul><ul><ul><li>thrombus </li></ul></ul><ul><ul><li>Non specific </li></ul></ul><ul><ul><li>ECG </li></ul></ul><ul><ul><li>Normal cardiac </li></ul></ul><ul><ul><li>enzymes </li></ul></ul><ul><ul><li>Occluding thrombus </li></ul></ul><ul><ul><li>sufficient to cause </li></ul></ul><ul><ul><li>tissue damage & mild </li></ul></ul><ul><ul><li>myocardial necrosis </li></ul></ul><ul><ul><li>ST depression +/- </li></ul></ul><ul><ul><li>T wave inversion on </li></ul></ul><ul><ul><li>ECG </li></ul></ul><ul><ul><li>Elevated cardiac </li></ul></ul><ul><ul><li>enzymes </li></ul></ul><ul><ul><li>Complete thrombus </li></ul></ul><ul><ul><li>occlusion </li></ul></ul><ul><ul><li>ST elevations on </li></ul></ul><ul><ul><li>ECG or new LBBB </li></ul></ul><ul><ul><li>Elevated cardiac </li></ul></ul><ul><ul><li>enzymes </li></ul></ul><ul><ul><li>More severe </li></ul></ul><ul><ul><li>symptoms </li></ul></ul>
  53. 58. ECG assessment ST Elevation or new LBBB STEMI Non-specific ECG Unstable Angina ST Depression or dynamic T wave inversions NSTEMI
  54. 59. Normal or non-diagnostic EKG
  55. 60. ST Depression or Dynamic T wave Inversions
  56. 61. ST-Segment Elevation MI
  57. 62. 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
  58. 63. Cardiac markers <ul><li>Troponin ( T, I) </li></ul><ul><ul><li>Very specific and more sensitive than CK </li></ul></ul><ul><ul><li>Rises 4-8 hours after injury </li></ul></ul><ul><ul><li>May remain elevated for up to two weeks </li></ul></ul><ul><ul><li>Can provide prognostic information </li></ul></ul><ul><ul><li>Troponin T may be elevated with renal dz, poly/dermatomyositis </li></ul></ul><ul><li>CK-MB isoenzyme </li></ul><ul><ul><li>Rises 4-6 hours after injury and peaks at 24 hours </li></ul></ul><ul><ul><li>Remains elevated 36-48 hours </li></ul></ul><ul><ul><li>Positive if CK/MB > 5% of total CK and 2 times normal </li></ul></ul><ul><ul><li>Elevation can be predictive of mortality </li></ul></ul><ul><ul><li>False positives with exercise, trauma, muscle dz, DM, PE </li></ul></ul>
  59. 64. AORTIC DISSECTION <ul><li>A BREACH IN INTEGRITY OF AORTIC WALL </li></ul><ul><li>ARTERIAL BLOOD BURSTS INTO MEDIA OF AORTA </li></ul><ul><li>MEDIA SPLITS IN TWO LAYERS. </li></ul><ul><li>FALSE LUMEN ALONGSIDE A TRUE LUMEN. </li></ul><ul><li>DOUBLE-BARRELLED OR BILUMINAL AORTA. </li></ul>
  60. 66. AORTIC DISSECTION PREDISPOSING FACTORS <ul><li>HTN </li></ul><ul><li>AORTIC ATHEROSCLEROSIS </li></ul><ul><li>NON-SPECIFIC AORTIC ANEURYSM </li></ul><ul><li>AORTIC COARCTATION </li></ul><ul><li>COLLAGEN DISORDERS MARFANS SYND,,,E D SYNDROME </li></ul><ul><li>FIBROMUSCULAR DYSPLASIA </li></ul><ul><li>PREVIOUS AORTIC SURGERY CABG AV REPLACEMENT </li></ul><ul><li>PREGNANCY(3 RD , TRIMESTER) </li></ul><ul><li>TRAUMA </li></ul><ul><li>IATROGENIC </li></ul>
  61. 67. AORTIC DISSECTION CLINICAL FEATURES <ul><li>TEARING PAIN </li></ul><ul><li>ABRUPT ONST </li></ul><ul><li>COLLAPSE </li></ul><ul><li>MARFAN`S SYNDROME </li></ul><ul><li>PT APPEARS TO BE IN SHOCK </li></ul><ul><li>BP---NORMAL OR RAISED </li></ul><ul><li>AC AR MAY DEVELOP </li></ul><ul><li>ASYMMETRY OF PULSES </li></ul><ul><li>MI </li></ul><ul><li>PARAPLEGIA(SPINAL) </li></ul><ul><li>ACUTE ABDOMEN(MESENTERIC CAELIAC) </li></ul><ul><li>RENAL FAILURE </li></ul><ul><li>ACUTE LIMB ISCHEMIA(LEGS) </li></ul>
  62. 68. TENSION PNEUMOTHORAX
  63. 69. PNEUMOTHORAX <ul><li>PRESENCE OF AIR IN PLEURAL SPACE </li></ul><ul><li>SPONTANEOUS PRIMARY SECONDARY </li></ul><ul><li>TRAUMATIC IATROGENIC NON-IATROGENIC </li></ul>
  64. 70. PNEUMOTHORAX CLINICAL FEATURES <ul><li>SUDDEN-ONSET UNILAT. CHEST PAIN </li></ul><ul><li>BREATHLESSNESS </li></ul><ul><li>ASYMPTOMATIC (NOT TENSION PNEUMOTHORAX) </li></ul><ul><li>DEC OR ABSENT BREATH SOUNDS (IF PNEUMOTHORAX MORE THAN15%). </li></ul><ul><li>RESONANT ON PERCUSSION </li></ul><ul><li>MEDIASTINAL DISPLACEMENT TO OPPOSITE SIDE </li></ul><ul><li>TACHYCARDIA </li></ul><ul><li>HYPOTENSION </li></ul><ul><li>CYANOSIS </li></ul><ul><li>TRACHEAL DISPLACEMENT </li></ul>
  65. 71. TENSION PNEUMOTHORAX DIAGNOSIS <ul><li>CLINICAL </li></ul><ul><li>CXR </li></ul>
  66. 73. PULMONARY EMBOLISM <ul><li>RISK FACTORS FOR THROMBOEMBOLISM </li></ul><ul><li>CLINICAL FEATURES DEPEND ON SIZE </li></ul><ul><li>FAINTNESS OR COLLAPSE </li></ul><ul><li>CENTRAL CHEST PAIN </li></ul><ul><li>APPREHENSION </li></ul><ul><li>SEVERE DYSPNOEA </li></ul><ul><li>PLEURITIC PAIN </li></ul><ul><li>HAEMOPTYSIS </li></ul>
  67. 74. PULMONARY EMBOLISM SIGNS <ul><li>MAJOR CIRCULATORY COLLAPSE TACHYCARDIA HYPOTENSION INC JVP RT.VENTRICULAR GALLOP RHYTHM SPLIT P2 SEVERE CYANOSIS DEC URINARY OUTPUT. </li></ul>
  68. 75. PULMONARY EMBOLISM INVESTIGATIONS <ul><li>CXR USUALLY NORMAL PULM;OPACITIES WEDGE-SHAPED OPACITY HORIZONTAL LINEAR OPACITIES PLEURL EFFUSION OLIGAEMIC LUNG FIELDS ENLARGED PULMONARY ARTERY ELEVATED DIAPHRAGM </li></ul>
  69. 76. PULMONARY EMBOLISM INVESTIGATIONS <ul><ul><ul><li>ECG S1 Q3 T3 RBBB SINUS TACHY RV HYPERTROPHY </li></ul></ul></ul>
  70. 77. PULMONARY EMBOLISM INVESTIGATIONS ABGs <ul><li>MAY BE NORMAL </li></ul><ul><li>OR </li></ul><ul><li>DEC;PaO2 DEC;PaCO2 METABOLIC ACIDOSIS </li></ul>
  71. 78. PULM; EMBOLISM INVESTIGATIONS <ul><li>D-DIMER </li></ul><ul><li>VENTILATION-PERFUSION SCANNING </li></ul><ul><li>CT PULMONARY ANGIOGRAPHY </li></ul><ul><li>MRI </li></ul><ul><li>COLLOR DOPPLER </li></ul><ul><li>ECHO </li></ul>
  72. 79. PLEURISY <ul><li>ANY DISEASE PROCESS INVOLVING PLEURA AND CAUSING PLEURITIC PAIN </li></ul><ul><li>COMMON FEATURE OF PULMONARY INFECTION AND INFARCTION </li></ul><ul><li>MAY OCCUR IN MALIGNANCY </li></ul>
  73. 80. PLEURISY <ul><li>PLEURAL PAIN </li></ul><ul><li>RIB MOVEMENT RESTRICTED </li></ul><ul><li>PLEURAL RUB </li></ul><ul><li>H/O RESP ILLNESS </li></ul><ul><li>CXR </li></ul>
  74. 81. TB
  75. 82. CONNECTIVE TISSUE DISORDERS CAUSING CHEST PAIN <ul><li>RHEUMATOID ARTHRITIS </li></ul><ul><li>SLE </li></ul><ul><li>SS </li></ul><ul><li>DMS </li></ul><ul><li>PMS </li></ul><ul><li>RHEUMATIC FEVER </li></ul>
  76. 83. CHEST MALIGNANCIES
  77. 84. RUPTURED OESOPHAGUS CAUSES <ul><li>MOST COMMON IATROGENIC (ENDOSCOPIC PERFORATION) </li></ul><ul><li>MALINANCY </li></ul><ul><li>CORROSIVE STRICTURES PERFORATION </li></ul><ul><li>POST RADIOTHERY STRICTURES </li></ul><ul><li>PERFORATED PEPTIC ULCER </li></ul><ul><li>SPONTANEOUS OESOPHAGEAL PERFORATION (BOERHAAVE SYNDROME) </li></ul>
  78. 86. RUPTURED OESOPHAGUS CLINICAL FEATURES <ul><li>SEVERE CHEST PAIN </li></ul><ul><li>SHOCK </li></ul><ul><li>SUB-CUTANEOUS EMPHYSEMA </li></ul><ul><li>PLEURAL EFFUSION </li></ul><ul><li>PNEUMOTHORAX </li></ul><ul><li>PNEUMOMEDIASTINUM </li></ul>
  79. 87. OESOPHAGEAL PAIN <ul><li>CAN MIMIC ANGINAL PAIN </li></ul><ul><li>MAY GET PRECIPITATED BY EXERCISE </li></ul><ul><li>MAY BE RELIEVED BY NITRATES </li></ul><ul><li>RELATION WITH SUPINE POSITION,EATING,DRINKING </li></ul><ul><li>H/O REFLUX </li></ul><ul><li>CAN RADIATE TO BACK </li></ul>
  80. 88. MYOCARDITIS PERICARDITIS <ul><li>PAIN ---- RETROSTERNAL OR IN THE SHOULDER </li></ul><ul><li>INTENSITY--- VARIES IN WITH MOVEMENT AND PHASE OF RESPIRATION </li></ul><ul><li>SHARP --- PAIN MAY CATCH THE PATIENT DURING COUGHING OR INSPIRATION </li></ul><ul><li>H/O PRODROMAL VIRAL ILLNESS </li></ul><ul><li>DYSPNEA </li></ul><ul><li>PERICARDIAL FRICTION RUB </li></ul><ul><li>FEVER </li></ul><ul><li>LEUCOCYTOSIS </li></ul>
  81. 89. ACUTE MYOCARDITIS <ul><li>INFECTIOUS </li></ul><ul><li>TOXIN/ DRUG INDUCED </li></ul><ul><li>IMMUNOLOGIC CAUSES </li></ul>VIRAL BACT RICKETTSIAL SPIROCHETAL FUNGAL PARASITIC
  82. 90. INFECTIOUS ACUTE MYOCARDITIS <ul><li>OFTEN FOLLOWS URTI </li></ul><ul><li>CHEST PAIN </li></ul><ul><li>S/O HEART FAILURE </li></ul><ul><li>ECG SHOW NON-SPECIFIC ST-T CHANGES CONDUCTION DISTURBANCES VENTRICULAR ECTOPY </li></ul><ul><li>CXR CARDIOMEGALY </li></ul>
  83. 91. PERICARDITIS <ul><li>INFLAMMATORY VIRAL TUBERCULAR BORRELIA BURGDORFERI(LYME DISEASE) </li></ul><ul><li>UREMIC PERICARDITIS </li></ul><ul><li>NEOPLASTIC </li></ul><ul><li>POST MI OR POST CARDIOTOMY DRESSLER`S SYNDROME </li></ul><ul><li>RADIATION </li></ul><ul><li>SLE </li></ul><ul><li>RA </li></ul><ul><li>DRUG-INDUCED </li></ul><ul><li>MYXEDEMA </li></ul>
  84. 92. PERICARDITIS SYMPTOMS <ul><li>PAIN ---- RETROSTERNAL OR IN THE SHOULDER </li></ul><ul><li>INTENSITY--- VARIES IN WITH MOVEMENT AND PHASE OF RESPIRATION </li></ul><ul><li>SHARP --- PAIN MAY CATCH THE PATIENT DURING COUGHING OR INSPIRATION </li></ul><ul><li>H/O PRODROMAL VIRAL ILLNESS </li></ul><ul><li>DYSPNEA </li></ul><ul><li>PERICARDIAL FRICTION RUB </li></ul><ul><li>FEVER </li></ul><ul><li>LEUCOCYTOSIS </li></ul>
  85. 93. PERICARDITIS ECG
  86. 94. PERICARDITIS <ul><li>CXR IN PERICARDITIS </li></ul><ul><li>SHOWS FLUID COLLECTION </li></ul><ul><li>MAY BE DRY </li></ul><ul><li>ECHO ADVISED </li></ul>
  87. 95. MITRAL VALVE PROLAPSE
  88. 96. MITRAL VALVE PROLAPSE <ul><li>SHARP LEFT SIDED CHEST PAIN </li></ul><ul><li>DYSPNEA </li></ul><ul><li>FATIGUE </li></ul><ul><li>PALPITATION </li></ul><ul><li>FEMALES </li></ul><ul><li>THIN </li></ul><ul><li>CHEST WALL DEFORMITIES </li></ul><ul><li>MID-SYSTOLIC CLICKS </li></ul><ul><li>ECHO </li></ul><ul><li>CARDIAC CATH </li></ul>
  89. 97. MUSCULOSKELETAL CHEST PAIN <ul><li>VARY WITH POSTURE </li></ul><ul><li>VARY WITH POSITION </li></ul><ul><li>LOCAL TENDERNESS </li></ul><ul><li>ARTHRITIS </li></ul><ul><li>COSTOCONDRITIS </li></ul><ul><li>INTERCOSTAL MUSCLE INJURY </li></ul><ul><li>COXSACKIE VIRAL INFECTION </li></ul><ul><li>MINOR SOFT TISSUE INJURIES </li></ul>
  90. 98. OSTEOARTHRITIS <ul><li>Localized DIS. </li></ul><ul><li>KNEE OR HIP INVOLVEMEMENT IS COMMON </li></ul><ul><li>PAIN ON MOVEMENT </li></ul><ul><li>CREPITUS </li></ul><ul><li>WORSE AT END OF DAY </li></ul><ul><li>TENDER JT. </li></ul>
  91. 99. TEITZE`S SYNDROME IDIOPATHIC COSTOCONDRITIS <ul><li>LOCALIZED PAIN/TENDERNESS AT COSTOCONDRAL JUNCTION </li></ul><ul><li>ENHANCED BY EMOTION,COUGHING,SNEEZING </li></ul><ul><li>2nd.RIB MOST AFFECTED </li></ul>
  92. 100. PROLAPSED DISC
  93. 101. HERPES ZOSTER
  94. 102. THANK YOU

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