A 63-year-old man presented to the emergency department with shortness of breath, chest pain, and lightheadedness. He had a history of smoking and alcohol use. On examination, he was pale, diaphoretic, and had distended jugular veins. Tests showed signs of pulmonary embolism including reduced oxygen levels and elevated D-dimer and cardiac markers. A CT scan confirmed multiple pulmonary embolisms. He was treated with oxygen supplementation, analgesics, and low molecular weight heparin to prevent further clot propagation.

1. Medical collage of wassit
Seminar about:
approach to chest pain
By:
Mustafa Bashar
Saif Saheb
Ahmed Ayad
Ali Akram
Ahmed Majed

2. A 63-year-old man presented to the
emergency department complaining of severe
shortness of breath that began abruptly when
he bent over to pick up some papers. He
reported that as he reached down he suddenly
was not able to catch his breath, felt
lightheaded, and collapsed to the floor without
any loss of consciousness.

3. He complain of severe central chest pain and
diaphoresis .
One week prior to this event, the patient
reported that he began to notice pain and
swelling in his right calf .

5. He had no significant past medical history .
Social history was significant for a 50 pack per
year smoking history and alcohol
consumption of approximately one bottle of
wine daily for many years .
His mother had a history of phlebitis. The
patient denied taking any medications and
had no known drug allergies

6. His vital signs upon arrival of emergency
medical services were a palpable systolic
blood pressure of 50 mmHg, a heart rate of
134 beats per minute, a respiratory rate of
40 per minute with an oxygen saturation of
80% breathing air. On arrival to the
emergency department, his oxygen
saturation was to 95% on a 100% non-rebreather
facemask

7. He was pale, diaphoretic, and unable to speak
in full sentences and low urinary output. His
jugular veins were distended to the angle of
the jaw while the patient was sitting upright
at 90 degrees and was later measured at
approximately 20 cm.

9. Cardiac exam
demonstrated tachycardia, a fixed wide of the
second heart sound, the presence of a third
heart sound at the left lower sternal border,
and a right ventricular heave

10. Pulmonary findings consisted of bilateral
crackles at the bases.
His extremities were cool and cyanotic with
weak peripheral pulses.

15. Show ventilation-perfution mismatch and
reduced cardiac output .also reduced Pao2
and low Paco2
D-dimer is elevated
Circulating markers such as troponin I & pro-brain
natriuretic peptide

18. diagnosis confirmed by
Ventilation-perfusion scanning has been the
most popular method of attempting to confirm the
presence of PE The sensitivity and specificity of V/Q
scanning is greatly increased when interpretation is
informed by clinical probability. A normal V/Q scan
virtually excludes PE and a low probability scan in the
presence of a low clinical probability makes PE unlikely.
Similarly, the presence of a high probability scan [VQ
mismatch ]in a patient with a high clinical probability
almost certainly establishes the diagnosis of PE. V/Q
scans are most useful in patients with normal
pulmonary architecture..

19. Colour doppler ultrasound of the leg to
confirm DVT in patiant with clinical
suspention of DVT
Echocardiography show acute dilatation of the
ventricle
Pulmonary CT angiography is the gold
standard for diagnosis

20. General measures
Oxygen
Opiates

21. Diuretics and vasodilators should be
Avoided
Resuscitation by external cardiac massage may
be successful in the moribund patient by
dislodging and breaking up a large central
embolus.

22. Low molecular weight heparin administered
subcutaneously is more effective than
intravenous unfractionated heparin and it is
easier to administer). The dose is standardized
for the weight of the patient and does not require
monitoring by tests of coagulation. Heparin is
effective in reducing mortality in PE by reducing
the propagation of clot and the risk of further
emboli. It should be administered for at least 5
days and anticoagulation continued using oral
warfarin. Heparin should not be discontinued
until the international normalized ratio (INR) is
greater than 2. An alternative for the initial LMWH
therapy is fondaparinux, which can be given as
a once-a-day SC injection of 2.5 mg, without
laboratory monitoring

23. Appears to improve outcome when acute
massive PE is accompanied by shock but it is
not clear whether there is any advantage of
thrombolysis over heparin in patients with a
normal blood pressure. Patients with PE
appear to have a high risk of intracranial
haemorrhage .

24. Caval filters
Patients who experience recurrent PE despite
adequate anticoagulation, or those patients in
whom anticoagulation is contraindicated, may
benefit from insertion of a filter in the inferior
vena cava below the origin of the renal
vessels. The introduction of retrievable caval
filters has been useful in patients with
temporary risk factors.

25. A 45 year old white male presents with chief
complaint of episodes of recurrent chest pain.
Past medical history is noncontributory. He says
the chest pain is like a deep pressure in the left
chest. It does not radiate and lasts just a few
minutes. It has occurred at rest and with
exercise, and occasionally with a big meal. It has
been reoccurring over the last several months. He
occasionally gets diaphoretic with the pain but
not always. He also has some dyspnea associated
with the chest pain when he has exercised. He is
not currently having pain, and his last epoisode
was this morning as he was shoveling snow off
his front walk

29. What`s next?

30. Cardiac enzym
Negative

33. Patients should be admitted urgently to
hospital
bed rest
antiplatelet therapy (aspirin 300 mg followed
by 75-325 mg daily long-term and
clopidogrel 300 mg followed by 75 mg daily
for 12 months
anticoagulant therapy (e.g. unfractionated or
fractionated heparin)

34. β-blocker (e.g. atenolol 50-100 mg daily or
metoprolol 50-100 mg 12-hourly)
A dihydropyridine calcium antagonist (e.g.
nifedipine or amlodipine) can be added to the
β-blocker, but may cause an unwanted
tachycardia if used alone; verapamil or
diltiazem is therefore the calcium antagonist
of choice if a β-blocker is contraindicated.
oral isosorbid dinitrate and If pain persists or
recurs, infusions of intravenous nitrates (e.g.
GTN or isosorbide dinitrate may help
Statin drugs should be used to stabilized the
plaque

35. A 45-year-old male presents to the local Emergency
Department with complaints of moderate to severe
chest pain, with radiation to the neck-shoulder
region. The patient denies any personal history of
heart disease, but reports that his father passed away
from a heart attack at the age of 69. Temperature =
38.3º c. Pulse = 110. Respiratory rate = 25. Blood
pressure = 100/63. During pulmonary auscultation,
the patient states that pain gets much worse every
time he is asked to take a deep breath. The patient
refuses to lie down for the abdominal exam, saying
that the pain gets too bad when he is supine. An EKG
is ordered, and shows ST elevation in all leads except
for V1 and aVR. PR depression is noted. Troponin I is
mildly elevated.

36. HISTORY Chest pain, which may
intense,retrosternal radiate to shoulders and
to the back but characteristically sharp,
pleuritic, and positional (relieved by leaning
forward); typically aggravated by deep
breathing, movement, a change of position,
exercise and swallowing.

37. Rapid pulse, pericardial friction rub, which may
vary in intensity and is loudest with pt sitting
forward.

44. Aspirin 650–975 mg qid or NSAIDs (e.g.,
indomethacin 25–75 mg qid); for severe,
refractory pain, prednisone 40–80 mg/d is
used and tapered over several weeks or
months. Intractable, prolonged pain or
frequently recurrent episodes may require
pericardiectomy. Anticoagulants are relatively
contraindicated in acute pericarditis because
of risk of pericardial hemorrhage

45. 1. Which of the following conditions
constitutes the most likely diagnosis in this
patient’s case?
A. myocardial infarction
B. Dressler’s syndrome
C. pericarditis
D. hypertrophic subaortic stenosis
E. cardiac tampanode

46. 2. Which of the following methods represents
the most appropriate next diagnostic step in
working up this patient’s condition?
A. angiography
B. CT scan
C. technetium-99 perfusion scan
D. magnetic resonance imaging
E. echocardiography

47. 3. Which of the following represents the most
appropriate treatment in the management of
this patient?
A. non-steroidal inflammatory drugs
B. cardiac catheterization with angioplasty
C. coronary artery bypass graft procedure
D. emergent IV administration of heparin
E. pericardiocentesis

48. 43 years old patient presents with sever chest
pain that will not stop. the pain are a
pressure that feels like an elephant sitting on
his chest. It radiates to his left arm and he is
very diaphoretic. He denies any dyspnea, but
he complain from nausea and vomiting. He
started having chest pain at home while
digging up a tree.

54.  Troponin appearing in 3-6 hours
 CK isoenzymes MB appearing 4-8 hours
 LDH within 24 hours and AST
 Erythrocyte Sedimentation Rate appearing 3
days after
 Leukocytes within several hours and peaking
within 2-4 days (if your in a rural area a stat
 CBC may give you a hint of possible
myocardial infarction)

55. Inferior infarcts involve the inferior portion of
the heart which sits on the diaphragm.
Irritation or somato-somatic reflexes could
cause nausea and vomiting due to adrenergic
innervation through common pathways.

56. EARLY MANAGEMENT
 Any Patients with suspected acute MI require
.immediate addmition to hospital
 High-flow oxygen
 I.v. access
 I.v. analgesia (opiates) and antiemetic : Intravenous
opiates (initially morphine sulphate 5-10 mg or
diamorphine 2.5-5 mg) and antiemetics (initially
metoclopramide 10 mg) should be administered
through an intravenous cannula and titrated by giving
repeated small doses until the patient is comfortable
 Aspirin 300 mg : chewing
 Heparin either infusion or low molecular weight S.c

57. Primary PCI or thrombolysis:
 Streptokinase, 1.5 million U in 100 ml of saline given
as an intravenous infusion over 1 hour-
 -alteplase: The standard regimen is given over 90
minutes (bolus dose of 15 mg, followed by 0.75
mg/kg body weight, but not exceeding 50 mg, over
30 minutes and then 0.5 mg/kg body weight, but not
exceeding 35 mg, over 60 minutes).
 tenecteplase -
 Reteplase -
 Intravenous heparin should be given for 48-72 hours
following thrombolysis with alteplase, TNK or
reteplase.

58.  Beta-blockers
 Intravenous β-blockers (e.g. atenolol 5-10 mg or
metoprolol 5-15 mg given over 5 minutes) relieve
pain, reduce arrhythmias and improve short-term
mortality in patients who present within 12 hours of
the onset of symptoms, but should be avoided if
there is heart failure, atrioventricular block or severe
bradycardia.
 Nitrates and other agents
 Sublingual glyceryl trinitrate (300-500 μg) is a
valuable first-aid measure in threatened infarction,
and intravenous nitrates (nitroglycerin 0.6-1.2
mg/hour or isosorbide dinitrate 1-2 mg/hour) are
useful for the treatment of left ventricular failure and
the relief of recurrent or persistent ischaemic pain.

59. A 18-year-old male patient came to the
emergency department with complaints of
sudden onset of pleuritic chest pain in the
left side stabbing in nature radiated to
epsilateral soulder and shortness of breath
after cough which started 6 hours ago. The
shortness of breath was mild in severity, the
symptoms worse by exertion and relieved
with rest

60.  Respiratory distress
 Tachypnea
 Asymmetric lung expansion.
 Decreased tactile fremitus
 Hyperresonance on percussion
 Distant or absent breath sounds

65. what is
treatment?

66. In many cases we need only observation and
serial CXR follow up daily , the air will be
absorbed.
In the simple(closed) spontanous
pneumothorax, if the volume of the air in that
side is less than 20% of the size of that
hemithorax and the patient has little
symptoms such as dyspnea ,then
conservative treatment is justified , however
if the underlying lung is diseased ( Tb ,
emphysema) active intervention is indicated
even if the size of the pneumothorax is near
20% of the hemithorax.

67. In the open type if the lung in serial CXR shows no
improvement ,then chest tube introduced in the
pleural space to facilitates lung expansion and
when the lung expands the pleural layers come in
contact with each other so the opening may seal
,sometimes we may use suction through the
chest tube to create more –ve pressure inside the
pleural space to help rapid lung expansion . If
this does not lead to re-expansion of the lung it
means that broncho-pleural fistula has been
developed and surgical repair is indicated
Tension pneumothorax is an emergency state and
needs urgent intervension, by chest tube .

68. 49-year-old male, otherwise healthy Presenting
complaint is retrosternal burning
pain , have been ongoing for approximately six
months At onset, retrosternal burning was
occurring one to two times per week, mainly after
meals
Symptoms do not worsen with activity or inspiration,
but often worse when bending over or lying flat
,Over the last month, symptoms have been
occurring on a daily basis, with the patient
occasionally awakening at night with similar
symptoms which disturb sleep

69. Patient appears generally well nourished
BP 132/70, pulse 84 bpm, afebrile
Current weight 102 kg; height 178 cm
No conjunctival pallor, no scleral icterus
Oral cavity normal, normal dentition
Save for central obesity, remainder of physical
exam within normal limits

72. When we do endoscope
for this patient ?

73. The presence of alarm signs – specifically
significant weight loss, dysphagia,
hematemesis, or melena – is an indication for
endoscopic evaluation to rule out esophageal
strictures or malignancy.

74. What`s the line of
treatment?

75. 1-change life style
2-medication
-antacid
-h2-antagonast
-PPI

76. 45 y .old male complaining of chest pain ,
burning, tickling, tingling, and/or numbness
occurs in the left parasternal area … Flu-like
symptoms (without a fever), such as chills,
.stomachache
Also there is Swelling and tenderness of the
lymph nodes …
then after 5 days the patient develop small .
area of rash Then blisters develop
Pain, described as "piercing needles in the skin
……

78. Q1 // what is the
most likely
diagnosis ??

79. Shingles
(( herpes zoster ))

80. Q2/ what are the investigations of choice
for such case ??

81. Investigation :
The diagnosis is usually clinical, based on typical
lesions in a single dermatome. Various techniques
to detect the virus or antibody detection may be
possible after consultation with a microbiologist.
Scraping for smears and cultures are usually
negative, as the viruses are difficult to recover
from the scrapes. A direct immunofluorescence
assay can be used; it is more sensitive than viral
culture and can differentiate herpes simplex viral
infections from varicella-zoster virus (VZV)
.infections
Where the presentation is atypical (eg, a young
patient, severe disease or a rash extending beyond
one dermatome), the patient needs to be
investigated for immunodeficiency.

82. Q3 // what are the treatment of
choice ???

83. TREATMENT :::
1 - Topical therapy ::
Topical antiviral treatment is not recommended. Topical
antibiotic treatment may be indicated for secondary
.bacterial infection
2- Oral antiviral therapy ::
Oral aciclovir has been shown to shorten the duration of
signs and symptoms
3- Steroids :
The use of oral corticosteroids in the treatment of
patients with zoster infection is controversial. As an
adjuvant option in the treatment of patients with acute
zoster infection, oral corticosteroids have been shown
to ameliorate the inflammatory features and so reduce
.pain, and cosmetically improve the rash

84. 4- Analgesia
It may be necessary to give quite strong
analgesia if there is pain. Corticosteroids,
tricyclic antidepressants, gabapentin, and
opioids reduce acute pain

85. Case
8

86. case 8
Awell nourished obese women admitted
to hospital to emergency room at mid
night … complaining from acute state of
shock with Sudden severe chest and upper
back pain, often described as a tearing
sensation, that radiates to the neck and
down the back between the scapula.
Also there is Shortness of breath and Sudden
difficulty speaking, loss of vision, weakness, of
one side of body, and Sweating
Then the patient loss her consciousness
at emergency department ..

87. physical examination findings
include the followings ( signs ) :
 Weak pulse in one arm compared to the
other .
 Hypotension
 muffled heart sounds
 diastolic murmur
 Asymmetrical pulses

88. What`s the
next ?

91. Q1// WHAT is THE
MOST LIKELY diagnosis
???

92. DISSECTING
AORTIC
ANEURISM

93. Q2// WHAT ARE
THE other
APPROPRIATE
INVESTIGATIONS
FOR SUCH CASE
???

94. 1- Transthoracic/transoesophageal ultrasound will give
an indication of site and extent of dissection
2- MRI scanning will confirm diagnosis, and identify
involvement of other vessels, and will be increasingly
useful as scanning times decrease, and with better
access. Of all of the imaging modalities it has the
best sensitivity (98%) and specificity (98%) .
3- Colour flow Doppler is useful for assessing aortic
regurgitation
4-ecg showing ACUTE MI like features (There
will be ECG signs of acute myocardial infarction if this
is present and this could lead to thrombolytic
therapy.

95.  Double aortic knob sign (present in 40% of
patients)
 Diffuse enlargement of the aorta with poor
definition or irregularity of the aortic contour
 Inward displacement of aortic wall calcification by
more than 10 mm
 Tracheal displacement to the right
 Pleural effusion (more common on the left side;
suggests leakage)
 Pericardial effusion
 Cardiac enlargement
 Left apical opacity

96. Q3// WHAT ARE THE
DDX ??

97. Differential diagnosis ::::
Acute coronary syndrome with and without ST
.elevation
.Aortic regurgitation without dissection
.Aortic aneurysms without dissection
.Musculoskeletal pain
.Pericarditis
.Mediastinal tumours
.Pleuritis
.Pulmonary embolism
Cholecystitis

98. Q3// WHAT ARE THE 
TREATMENT ??

99. TX :
A -
General measures -
.Intravenous access
.Adequate analgesia - eg, morphine
.Transfer to an intensive care unit or high dependency unit
aggressive blood pressure control
.
There may be evidence of blood loss due to sequestration of
blood. Separate lines are required for administration of blood
.and drugs

100. Surgery
Surgical intervention may involve the placing
of stents or grafts to the aorta but accurate
assessment is essential first, as there may
be entry, re-entry and multiple tears

103. Case :
19-years old alcoholic male came to doctor
complaining of sever epigastric pain radiated to
back and chest ,with nausea and vomiting,
increased heart rate with fever and weakness .the
patient had history of gallbladder stone, ,

104. What`s the next 
?

106. Laboratory investigations: show>>
serum amylase ………………..elevated
bilirubin ……………... elevated
serum alkaline phosphate.. elevated
AST&ALT …………elevated

107. -Ultrasound can show a swollen pancreas,
dilated common bile duct and free
peritoneal fluid .
-It is useful to detect the presence of
gallstones

108. What are the likely 
dx ?????

109. Acute pancreatitis

110. Other mode for dx ?
1.C.T
2.Chest X-ray

112. treatment::::
 Self care at home
 Stop alcohol
 Diet improvement
 Medical care
 Objective- relieve symptoms and stop progression
 Admit to hospital
 Maintenance of oxygenation
 Maintenance of IV line
 Medication for pain and nausea
 Antibiotics in certain settings
 Bowel rest by NPO
 Nasogastric intubation
 Nutritional supplementation

113.  Surgery
 Only done to remove the etiological factor e- g
cholecystectomy in case of gall stones
 Early ERCP and sphincterectomy with stone
extraction
 In complicated cases surgical procedures
required as per consultation

114. General information

115.  Present on Admission:
 Age greater than 55 years
 WBC greater than 16,000/ul
 Blood glucose greater than 200 mg/dl
 Serum LDH greater than 350 I.U./L
 SGOT (AST) greater than 250 I.U./L

116.  Hematocrit fall greater than 10%
 BUN increase greater than 8 mg/dl
 Serum calcium less than 8 mg/dl
 Arterial oxygen saturation less than 60 mm
Hg
 Base deficit greater than 4 m eq/L
 Estimated fluid sequestration greater than
6000 ml (6 liters)

117. A 20-years old female presented 
with pain in right upper quadrant
and referred pain of right shoulder
tip also nausea ,vomiting ,fever on
examination revealed right
hypochondrial tenderness , rigidity
and gallbladder mass,what is your
next step?

118. What are the most likely dx ??? 

119. Acute cholecyctitis

120. What are the
investigations
???

121. FBC . - the WbC are raised
.Liver enzymes are mildly abnormal
:Ultrasound findings for cholecystitis
Include a thickened gallbladder wall (greater than 3
mm) and may also include pericholecystic fluid or
.air in the gallbladder or the gallbladder wall
If the gallbladder wall is thickened but there are no
gallstones present then the diagnosis could still be
acalculus cholecystitis

122. What are the treatment ???

123. : treatment
Bed rest ,pain relief(diclofenac or pethidine) ,antibiotic and maintenance of
fluid balance.
If your GP suspects you have acute cholecystitis, you will probably be admitted
.to hospital for treatment
Antibiotics
You will first be given an injection of antibiotics into a vein. Broad-spectrum
.antibiotics are used, which can kill a wide range of different bacteria
Once your symptoms have stabilised, you may be sent home and given an
appointment to return for surgical treatment
Alternatively, if your symptoms are particularly severe or you have a high risk
of complications, you may be referred for surgery a few days after antibiotic
.treatment
A cholecystectomy is the most widely used type of surgery for cases of acute
.cholecystitis

124. thanx