APPROACH TO APPROACH TO CHEST PAINCHEST PAIN

OBJECTIVESOBJECTIVES

1. Establish a differential diagnosis for chest pain 1. Establish a differential diagnosis for chest pain

2. Know what clues to obtain on history to rule-in or out MI, PE, 2. Know what clues to obtain on history to rule-in or out MI, PE, pneumothorax and pericarditis. pneumothorax and pericarditis.

3. Identify risk factors for MI and PE 3. Identify risk factors for MI and PE

4. Know how to do a focused physical exam, identifying features 4. Know how to do a focused physical exam, identifying features that would distinguish between MI, PE, pneumothorax, that would distinguish between MI, PE, pneumothorax, pericarditis, tamponade, pneumonia, and aortic dissection. pericarditis, tamponade, pneumonia, and aortic dissection.

5. Identify investigations required in diagnosing MI, PE, 5. Identify investigations required in diagnosing MI, PE, pneumothorax and pneumonia and how to interpret results. pneumothorax and pneumonia and how to interpret results.

6. Outline management strategy in MI, PE, peumothorax and 6. Outline management strategy in MI, PE, peumothorax and pneumonia. pneumonia.

When assessing a patient with When assessing a patient with chest pain, ruling-out the most life-chest pain, ruling-out the most life-

threatening causes is most threatening causes is most important. important.

CASE 1CASE 1

A 65 year-old male presents with a 2-hour A 65 year-old male presents with a 2-hour history of central chest pain. He describes it history of central chest pain. He describes it as “though an elephant is sitting on my as “though an elephant is sitting on my chest”. He gets similar symptoms when chest”. He gets similar symptoms when walking 2 blocks and is relieved with rest. walking 2 blocks and is relieved with rest. Today’s episode began after he walked to Today’s episode began after he walked to the bathroom and was not relieved by rest. the bathroom and was not relieved by rest.

What is the most likely diagnosis? What What is the most likely diagnosis? What other clues in his history would support the other clues in his history would support the diagnosis? diagnosis?

What is the difference between stable What is the difference between stable angina and unstable angina?angina and unstable angina?

What is acute coronary syndrome and how What is acute coronary syndrome and how do you diagnose it?do you diagnose it?

The patient’s BP is 140/75 and his HR is 110 The patient’s BP is 140/75 and his HR is 110 and regular. His JVP is at 3 cm, he has no and regular. His JVP is at 3 cm, he has no crackles, no murmurs and no peripheral crackles, no murmurs and no peripheral edema. edema.

What physical signs must you look for in-What physical signs must you look for in-order to rule out aortic dissection?order to rule out aortic dissection?

Describe the changes on the ECG.Describe the changes on the ECG.

What is your diagnosis?What is your diagnosis?

What investigations would you like to What investigations would you like to send?send?– Describe the pattern of change in cardiac Describe the pattern of change in cardiac

enzymes pertaining to time.enzymes pertaining to time.

How would you manage him?How would you manage him?– What is the difference between low molecular What is the difference between low molecular

weight heparin and unfractionated heparin?weight heparin and unfractionated heparin?– What parameters do you monitor if patient is What parameters do you monitor if patient is

on the above mentioned drugs.on the above mentioned drugs.– What medications should he be given prior to What medications should he be given prior to

discharge?discharge?– How do you risk stratify him in the future?How do you risk stratify him in the future?

Let us suppose that his ECG showed Let us suppose that his ECG showed the following.the following.

Describe the changes seen.Describe the changes seen.

What is your diagnosis? What is your diagnosis?

Describe your management plan in detail.Describe your management plan in detail.

What are the indications and What are the indications and contraindications for thrombolysis?contraindications for thrombolysis?– How do you assess if thrombolysis is How do you assess if thrombolysis is

successful?successful?– What are the possible complications of What are the possible complications of

thrombolysis?thrombolysis?

The patient stabilizes and is admitted to The patient stabilizes and is admitted to the CCU. He develops chest pain again 2 the CCU. He develops chest pain again 2 days later but of a different quality. The days later but of a different quality. The pain is worse when he is supine and pain is worse when he is supine and improves when he sits up. improves when he sits up.

Repeat ECG is as follows :Repeat ECG is as follows :

Describe the changes and state your Describe the changes and state your diagnosis.diagnosis.

What diagnostic clues are available from What diagnostic clues are available from his history?his history?

Are there additional tests which would be Are there additional tests which would be helpful to confirm your diagnosis?helpful to confirm your diagnosis?

Describe how you will manage this Describe how you will manage this patient.patient.

What lifestyle advice would you give What lifestyle advice would you give this patient on discharge?this patient on discharge?

CASE 2CASE 2

A 78 year-old woman presents with A 78 year-old woman presents with sudden-onset, sharp right-sided chest sudden-onset, sharp right-sided chest pain. She has been coughing since the pain. She has been coughing since the onset of her pain and has noted that she is onset of her pain and has noted that she is dyspneic. Her pain significantly worsens dyspneic. Her pain significantly worsens with inspiration. with inspiration.

1) What diagnoses are you considering? 1) What diagnoses are you considering?

2) What additional history do you need? 2) What additional history do you need?

She then develops hemoptysis, with She then develops hemoptysis, with a total 10mls of blood.a total 10mls of blood.

SpO2 was 80%, BP98/60, HR 127, T SpO2 was 80%, BP98/60, HR 127, T 37.7°C37.7°C

What would you look for on physical What would you look for on physical examination?examination?

What tests would you order?What tests would you order?

ABG :ABG :– pH 7.33pH 7.33– pCO2 3.5 kPapCO2 3.5 kPa– pO2 7.5 kPapO2 7.5 kPa– HCO3 20 mmol/LHCO3 20 mmol/L– Interpret the ABGInterpret the ABG

Describe the findings on the CXR and Describe the findings on the CXR and ECG.ECG.

What other ECG changes is helpful to What other ECG changes is helpful to diagnose this condition?diagnose this condition?

What other tests helps in diagnosing What other tests helps in diagnosing this disorder?this disorder?

What test is diagnostic?What test is diagnostic?

How would you manage her after How would you manage her after confirming your diagnosis?confirming your diagnosis?

CASE 3CASE 3 A 23 year-old man with presents to the ER A 23 year-old man with presents to the ER

with acute onset of sharp left-sided chest with acute onset of sharp left-sided chest pain and SOB. His BP is 80/60 and he has pain and SOB. His BP is 80/60 and he has decreased breath sounds on the right side decreased breath sounds on the right side and hyperesonance on percussion. and hyperesonance on percussion.

1) What is the most likely diagnosis? 1) What is the most likely diagnosis?

2) What is your next step?2) What is your next step?

Describe the CXR findings?Describe the CXR findings?

How would you manage this How would you manage this condition?condition?– What are the indications for insertion of What are the indications for insertion of

a chest tube?a chest tube?

What are the causes of this What are the causes of this condition?condition?