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1. Approach to A Patient with
Chest Pain
Presenter:
Dr. Salem Sultan

2. HOW TO APPROACH CHEST PAIN?
1. HISTORY TAKING.
2. PHYSICAL EXAMINATION.
3. INVESTIGATION.
4. TREATMENT.
Salem Alatef Sultan
Medical college, Najran university, KSA

3. Cardiac cause
Non-cardiac cause
Ischemic cardiac
Non-ischemic cardiac
Stable angina
Unstable angina
Acute myocardial infarction
Pericarditis
Vascular
Pulmonary
Gastrointestinal
Musculoskeletal
Aortic dissection
Pulmonary embolism
Pneumonia
GERD
Costal inflammation
Differential diagnosis
of Chest pain:
Salem Alatef Sultan
Medical college, Najran university, KSA

4. ACUTE CORONARY SYNDROME
Salem Alatef Sultan
Medical college, Najran university, KSA

5. Salem Alatef Sultan
Medical college, Najran university, KSA

6. Salem Alatef Sultan
Medical college, Najran university, KSA

7. S O C R A T E S
Site
Diffuse, difficult
to localize
Onset
Gradually
Character
Heaviness
Radiation
Jaw, neck,
back, shoulder
and both
arms.
Relieving
administration
of therapeutic
interventions
nitroglycerin
2
Associated
symptoms
shortness of
breath, nausea,
indigestion,
vomiting,
diaphoresis,
dizziness, and
fatigue
Timing
more than
20 minutes
Exacerbation
exercise
Severity
Very severe
Salem Alatef Sultan
Medical college, Najran university, KSA

8. Salem Alatef Sultan
Medical college, Najran university, KSA

9. HISTORY TAKING – RISK FACTORS
• Smoking
• Hypertension
• Diabetes Mellitus
• Dyslipidemia
• Low HDL < 40
• Elevated LDL / TG
• Family History—event in first
degree relative >55 male/65
female
•Age-- > 45 for male/55 for female
•Chronic Kidney Disease
•Lack of regular physical activity
•Obesity
•Lack of diet rich in fruit, veggies,
fiber
Salem Alatef Sultan
Medical college, Najran university, KSA

10. Physical Examination
• Systemic hypoperfusion:
• hypotension;
• tachycardia;
• impaired cognition;
• cool, clammy, pale, ashen skin
Salem Alatef Sultan
Medical college, Najran university, KSA

11. Levine sign
Jugular venous distension
Salem Alatef Sultan
Medical college, Najran university, KSA

12. Investigation
• ECG
• Cardiac marker: Troponin ( T, I) also can distinguish NSTEMI from UA
• Echocardiography
• Myocardial perfusion imaging
• Coronary angiography: evidence of coronary artery narrowing.
Salem Alatef Sultan
Medical college, Najran university, KSA

13. Salem Alatef Sultan
Medical college, Najran university, KSA

14. Salem Alatef Sultan
Medical college, Najran university, KSA

15. Salem Alatef Sultan
Medical college, Najran university, KSA

16. Salem Alatef Sultan
Medical college, Najran university, KSA

17. CARDIAC TAMPONADE
Salem Alatef Sultan
Medical college, Najran university, KSA

18. • In cardiac tamponade, the primary abnormality is compression of all
cardiac chambers due to increased pericardial pressure
• The following consequences result from this constrained cardiac
filling:
1. Progressive changes in systemic venous return
2. Respiratory variation in venous return
3. Acute bleeding
4. By comparison, chronic accumulation of a pericardial effusion
Salem Alatef Sultan
Medical college, Najran university, KSA

19. Salem Alatef Sultan
Medical college, Najran university, KSA

20. CLINICAL PRESENTATION
• Chest pain
• Syncope or presyncope
• Dyspnea and tachypnea
• Hypotension
• Tachycardia
• Peripheral edema
• Elevated jugular venous pressure
• Pulsus paradoxus
Salem Alatef Sultan
Medical college, Najran university, KSA

21. Investigations
• Electrocardiography
• Chest radiograph
• Echocardiography
Salem Alatef Sultan
Medical college, Najran university, KSA

22. Salem Alatef Sultan
Medical college, Najran university, KSA

23. “Water bottle” sign
Salem Alatef Sultan
Medical college, Najran university, KSA

24. Treatment
• Definitive treatment of cardiac tamponade is achieved by removal of
the pericardial fluid percutaneous or surgical drainage — Both
percutaneous drainage (ie, pericardiocentesis)
• Volume repletion
• Inotropic agents: Dobutamine
• Positive pressure ventilation
Salem Alatef Sultan
Medical college, Najran university, KSA

25. Salem Alatef Sultan
Medical college, Najran university, KSA

26. Salem Alatef Sultan
Medical college, Najran university, KSA

27. AORTIC DISSECTION
Salem Alatef Sultan
Medical college, Najran university, KSA

28. Salem Alatef Sultan
Medical college, Najran university, KSA

29. History
• Acute substernal tearing sensation, with radiation to intrascapular region
of the back.
• Pain may migrate with the propagation of the dissection,
• Stroke, acute MI due to obstruction of aortic branches
• Dyspnoea due to acute aortic regurgitation, hypotension due to cardiac
tamponade
• History of hypertension and smoking .
Salem Alatef Sultan
Medical college, Najran university, KSA

30. Physical Examination
• unequal pulses or BPs in both arms
• New diastolic murmur due to aortic regurgitation
• Muffled heart sounds if the dissection is complicated by cardiac tamponade,
• New focal neurological findings( syncope and altered mental status ).
Salem Alatef Sultan
Medical college, Najran university, KSA

31. Investigation
• CT chest with contrast:
false lumen or flap in the ascending or
descending aorta.
• MRI angiography:
false lumen or flap in the ascending or
descending aorta.
Very accurate, but limited availability in
the acute setting.
Salem Alatef Sultan
Medical college, Najran university, KSA

32. Treatment
• Admition
• Medical management ( if not leaking or ruptured ) :
reduce cardiac contractility (beta blockers )
reduce systemic arterial pressure (Calcium channel blockers )
• Surgury
Salem Alatef Sultan
Medical college, Najran university, KSA

33. CORONARY ARTERY VASOSPASM
Salem Alatef Sultan
Medical college, Najran university, KSA

34. Salem Alatef Sultan
Medical college, Najran university, KSA

35. History
• retrosternal pain or pressure with radiation to the neck, jaw, left
shoulder, or arm
• occur at rest
• Distinguishing unstable angina pectoris related to coronary
atherosclerosis from variant angina may be difficult and require
special investigations for diagnosis, including coronary angiography.
Salem Alatef Sultan
Medical college, Najran university, KSA

36. Physical examination
• No features on physical examination are specific for vasospastic
angina.
• Signs may be absent between symptomatic episodes.
• During periods of angina, physical findings relating to ischemia and
ventricular dysfunction may be present, including rales, jugular
venous distention, peripheral edema, extra heart sounds, ectopy or
other arrhythmia.
Salem Alatef Sultan
Medical college, Najran university, KSA

37. Management
• admission.
• ECG
• serial cardiac enzyme and troponin
• Initial medical treatment should include sublingual, topical, or intravenous (IV)
nitrate therapy.
• Until atherosclerotic coronary disease is excluded, standard therapies, including
antiplatelet or antithrombotic agents, statins, and beta blockers, may be
administered.
• Once the diagnosis of coronary artery vasospasm is made, calcium channel
blockade and long-acting nitrates may be used for long-term prophylaxis.
• Percutaneous and Surgical Revascularization (if patients continue to have
vasospasm despite medical therapy)
Salem Alatef Sultan
Medical college, Najran university, KSA

38. PULMONARY EMBOLISM
Salem Alatef Sultan
Medical college, Najran university, KSA

39. Pulmonary Embolism
• Pulmonary emboli usually arise from thrombi that originate in the
deep venous system of the lower extremities; however, they rarely
also originate in the pelvic, renal, upper extremity veins, or the right
heart chambers.
• After traveling to the lung, large thrombi can lodge at the bifurcation
of the main pulmonary artery or the lobar branches and cause
hemodynamic compromise.
Salem Alatef Sultan
Medical college, Najran university, KSA

40. Etiology
• Virchow triad, which consists of the following :
• Endothelial injury
• Stasis or turbulence of blood flow
• Blood hypercoagulability
• multifactorial include the following:
• Immobilization, Surgery and trauma, Pregnancy, Oral contraceptives
and estrogen replacement , Acute medical illness
Salem Alatef Sultan
Medical college, Najran university, KSA

41. Signs and symptoms
• The classic presentation of pulmonary embolism is the abrupt onset
of pleuritic chest pain, shortness of breath, and hypoxia. However,
most patients with pulmonary embolism have no obvious symptoms
at presentation .
• Some may present with atypical symptoms :-
• Seizures , Fever, Wheezing, Hemoptysis
Salem Alatef Sultan
Medical college, Najran university, KSA

42. History
• The challenge in dealing with pulmonary embolism is that patients
rarely display the classic presentation of this problem , so you must
ask about risk factors :-
• Immobilization , Surgery and trauma, Malignancy, Hereditary factors ,
Hemolytic anemias , Hyperlipidemias, Travel of 4 hours or more,
Smoking, Stroke , Prior PE, DVT
Salem Alatef Sultan
Medical college, Najran university, KSA

43. Physical Examination
• Physical examination findings are quite variable has been reported as
follows:
• Tachypnea %96
• Rales - 58%
• Accentuated second heart sound - 53%
• Tachycardia - 44%
• Fever
• Diaphoresis , S3 or S4 gallop , Lower extremity edema , Cardiac
murmur , Cyanosis
Salem Alatef Sultan
Medical college, Najran university, KSA

44. Investigations
• D-dimer
• Spiral CT chest
• Pulmonary Angiography “Gold Standard”
Salem Alatef Sultan
Medical college, Najran university, KSA

45. Treatment
Goals are :-
• Prevent death from a current embolic event
• Reduce the likelihood of recurrent embolic events
• Minimize the long-term morbidity of the event
Salem Alatef Sultan
Medical college, Najran university, KSA

46. Treatment
• Anticoagulation
• Thrombolytic therapy
• Surgery
• Vena Cava Filters
Salem Alatef Sultan
Medical college, Najran university, KSA

47. PNEUMONIA
Salem Alatef Sultan
Medical college, Najran university, KSA

48. pneumonia
Pneumonia can be generally defined as:-
an infection of the lung parenchyma, in which consolidation of the
affected part and a filling of the alveolar air spaces with exudate,
inflammatory cells, and fibrin is characteristic. [4] Infection by bacteria
or viruses is the most common cause, although infection by other
micro-orgamisms such as fungi and yeasts, and mycobacteria may
occur.
Salem Alatef Sultan
Medical college, Najran university, KSA

49. Etiology
• pneumonias infectious agents, which include pneumococcal
agents; Haemophilus influenzae; Klebsiella, Staphylococcus,
and Legionella species Microaspiration of organisms that colonize the
upper respiratory tract and mucosal surfaces is probably the most
common mode of infection. Some agents,
notably Staphylococcus species, may be spread hematogenously.
Salem Alatef Sultan
Medical college, Najran university, KSA

50. Risk factors
Coinfection with H1N1 influenza increases the risk of secondary
bacterial pneumonia, with S pneumoniae the most likely coinfection
Other risk factors include local lung pathologies (eg, tumors, chronic
obstructive pulmonary disease [COPD], bronchiectasis), smoking
Salem Alatef Sultan
Medical college, Najran university, KSA

51. Signs and symptoms
• Cough, particularly cough productive of sputum, is the most
consistent presenting symptom of bacterial pneumonia and may
suggest a particular pathogen, as follows
• Streptococcus pneumoniae: Rust-colored sputum
• Pseudomonas, Haemophilus, and pneumococcal species: May
produce green sputum
• Klebsiella species pneumonia: Red currant-jelly sputum
• Anaerobic infections: Often produce foul-smelling or bad-tasting
sputum
Salem Alatef Sultan
Medical college, Najran university, KSA

52. Signs and symptoms
• Signs of bacterial pneumonia may include the following:-
• Hyperthermia or hypothermia
• Tachypnea
• Use of accessory respiratory muscles
• Tachycardia
• Central cyanosis
• Altered mental status
Salem Alatef Sultan
Medical college, Najran university, KSA

53. Physical findings
• Abnormal breath sounds, such as rales/crackles, rhonchi, or wheezes
• Decreased intensity of breath sounds
• Whispering pectoriloquy
• Dullness to percussion
• Tracheal deviation
• Lymphadenopathy
• Pleural friction rub
Salem Alatef Sultan
Medical college, Najran university, KSA

54. Diagnosis
• laboratory tests include
• CBC
• Sputum evaluation:-
• Sputum Gram stain and culture should be performed before initiating
antibiotic therapy. A single predominant microbe should be noted at
Gram staining, although mixed flora may be observed with anaerobic
infection caused by aspiration
Salem Alatef Sultan
Medical college, Najran university, KSA

55. Diagnosis
• Pathogen-specific tests
• Urine assays
• Sputum, serum, and/or urinary antigen tests
• Immune serologic tests
• Imaging studies :-
• Chest radiography: The criterion standard for establishing the
diagnosis of pneumonia
• Chest computed tomography scanning
• Chest ultrasonography
Salem Alatef Sultan
Medical college, Najran university, KSA

56. patient with bilateral lower lobe
pneumonia. Note the spine sign, or
loss of progression of radiolucency
of the vertebral bodies
Salem Alatef Sultan
Medical college, Najran university, KSA

57. Management
• The mainstay of drug therapy for bacterial pneumonia is antibiotic
treatment. First-line antimicrobials for S pneumoniae, the most
prevalent cause of bacterial pneumonia, are, for the penicillin-
susceptible form of the bacterium, penicillin G and amoxicillin. For
the penicillin-resistant form of S pneumoniae, first-line agents are
chosen on the basis of sensitivity.
Salem Alatef Sultan
Medical college, Najran university, KSA

58. Supportive measures
• Analgesia and antipyretics
• Chest physiotherapy
• Intravenous fluids
• Pulse oximetry
• Oxygen supplementation
• Positioning of the patient to minimize aspiration risk
• Respiratory therapy, including treatment with bronchodilators
• Suctioning and bronchial hygiene
Salem Alatef Sultan
Medical college, Najran university, KSA

59. Quize
What is the most common pathogen can cause pneumonia ?
A- staph areus
B- Pseudomonas
C- Streptococcus pneumoniae
D – Haemophilus
Salem Alatef Sultan
Medical college, Najran university, KSA

60. PNEUMOTHORAX
Salem Alatef Sultan
Medical college, Najran university, KSA

61. Pneumothorax
• Pneumothorax is defined as the
presence of air or gas in the
pleural cavity which can impair
oxygenation and/or ventilation.
Salem Alatef Sultan
Medical college, Najran university, KSA

62. • Risk Factors:
1. Smoking
2. Age less tan 40
3. Recent invasive chest surgery
4. Chest trauma
5. COPD.
• Clinical presentation:
1. Chest pain
2. Dyspnea
3. Hyper expanded chest.
4. Hyper resonant on percussion.
5. Diminished or absent breath
sound.
6. Shifted trachea.
Salem Alatef Sultan
Medical college, Najran university, KSA

63. Investigation
• Chest X ray:
As little as 50 mL of pleural gas
can be visible in the upright
position. Approximately 500 mL
of intrapleural gas is necessary to
visualise a pneumothorax in
supine patients.
Salem Alatef Sultan
Medical college, Najran university, KSA

64. • CT scan:
A CT scan of the chest is more sensitive than a chest radiograph or
ultrasound in detecting pneumothoraces. It is often used in patients
with multiple traumatic injuries or where an occult pneumothorax is
suspected.
• Ultra sound:
In the hands of experienced practitioners, ultrasound has a reasonable
sensitivity and specificity for the diagnosis of a pneumothorax.
Salem Alatef Sultan
Medical college, Najran university, KSA

65. Treatment
1. Needle decompression:
Achieved by immediate insertion of a standard 14-gauge intravenous
catheter into the pleural space at the intersection of the midclavicular
line and the second or third intercostal space on the side of the
pneumothorax.
2. Oxygen Therapy.
3. Tube thoracostomy:
After needle decompression, the patient will require a chest tube or
small-bore catheter to reduce the risk of an immediate recurrence of
the tension pneumothorax.
Salem Alatef Sultan
Medical college, Najran university, KSA

66. GASTROESOPHAGEAL REFLUX DISEASE
Salem Alatef Sultan
Medical college, Najran university, KSA

67. Gastro Esophageal Reflux Disease (GERD)
• 'symptoms or complications resulting from the reflux of gastric
contents into the [o]esophagus or beyond, into the oral cavity
(including larynx) or lung'.
Salem Alatef Sultan
Medical college, Najran university, KSA

68. • Risk Factors:
1. Old age.
2. Hiatus hernia.
3. Obesity.
4. Psyclogical stress.
5. Asthma.
Clinical presentation:
1. Heartburn
2. Dysphagia
3. Halitosis
4. Chest pain
Salem Alatef Sultan
Medical college, Najran university, KSA

69. Investigation
1. Oesophagogastroduodenoscopy
(OGD).
2. PH monitoring
3. Barium swallow.
Salem Alatef Sultan
Medical college, Najran university, KSA

70. Treatment
1. PPI
2. H2 antagonist
3. Life style changes
4. Surgery
Salem Alatef Sultan
Medical college, Najran university, KSA

71. ANY QUESTION

72. THANK YOU
FOR YOUR ATTENTION