Download Chest Pain - I Do Not Agree

APPROACH TO
CHEST PAIN
OBJECTIVES

1. Establish a differential diagnosis for chest pain

2. Know what clues to obtain on history to rule-in or out MI,
PE, pneumothorax and pericarditis.

3. Identify risk factors for MI and PE

4. Know how to do a focused physical exam, identifying
features that would distinguish between MI, PE,
pneumothorax, pericarditis, tamponade, pneumonia, and
aortic dissection.

5. Identify investigations required in diagnosing MI, PE,
pneumothorax and pneumonia and how to interpret results.

6. Outline management strategy in MI, PE, peumothorax
and pneumonia.
When assessing a patient with
chest pain, ruling-out the most lifethreatening causes is most
important.
CASE 1

A 65 year-old male presents with a 2-hour
history of central chest pain. He describes it
as “though an elephant is sitting on my
chest”. He gets similar symptoms when
walking 2 blocks and is relieved with rest.
Today’s episode began after he walked to
the bathroom and was not relieved by rest.



What is the most likely diagnosis? What
other clues in his history would support the
diagnosis?
What is the difference between stable
angina and unstable angina?
What is acute coronary syndrome and how
do you diagnose it?


The patient’s BP is 140/75 and his HR is 110
and regular. His JVP is at 3 cm, he has no
crackles, no murmurs and no peripheral
edema.
What physical signs must you look for inorder to rule out aortic dissection?

Describe the changes on the ECG.

What is your diagnosis?

What investigations would you like to
send?
– Describe the pattern of change in cardiac
enzymes pertaining to time.

How would you manage him?
– What is the difference between low molecular
weight heparin and unfractionated heparin?
– What parameters do you monitor if patient is
on the above mentioned drugs.
– What medications should he be given prior to
discharge?
– How do you risk stratify him in the future?
 Let
us suppose that his ECG showed
the following.
 Describe
 What
the changes seen.
is your diagnosis?


Describe your management plan in detail.
What are the indications and
contraindications for thrombolysis?
– How do you assess if thrombolysis is
successful?
– What are the possible complications of
thrombolysis?


The patient stabilizes and is admitted to
the CCU. He develops chest pain again 2
days later but of a different quality. The
pain is worse when he is supine and
improves when he sits up.
Repeat ECG is as follows :



Describe the changes and state your
diagnosis.
What diagnostic clues are available from
his history?
Are there additional tests which would be
helpful to confirm your diagnosis?
 Describe
patient.
 What
how you will manage this
lifestyle advice would you give
this patient on discharge?
CASE 2

A 78 year-old woman presents with
sudden-onset, sharp right-sided chest
pain. She has been coughing since the
onset of her pain and has noted that she
is dyspneic. Her pain significantly worsens
with inspiration.

1) What diagnoses are you considering?

2) What additional history do you need?
 She
then develops hemoptysis, with
a total 10mls of blood.
 SpO2 was 80%, BP98/60, HR 127, T
37.7°C
 What
would you look for on physical
examination?


What tests would you order?
ABG :
– pH 7.33
– pCO2 3.5 kPa
– pO2 7.5 kPa
– HCO3 20 mmol/L
– Interpret the ABG
 Describe
ECG.
 What
the findings on the CXR and
other ECG changes is helpful to
diagnose this condition?
 What
other tests helps in diagnosing
this disorder?
 What
test is diagnostic?
 How
would you manage her after
confirming your diagnosis?
CASE 3

A 23 year-old man with presents to the ER
with acute onset of sharp left-sided chest
pain and SOB. His BP is 80/60 and he has
decreased breath sounds on the right side
and hyperesonance on percussion.

1) What is the most likely diagnosis?

2) What is your next step?
 Describe
the CXR findings?
 How
would you manage this
condition?
– What are the indications for insertion of
a chest tube?
 What
are the causes of this
condition?