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Chest pain
- 1. The Medical Beast Page 1 CHEST PAIN Diagnostic Pathophysiology Past history Complains Physical signs ECG Chest X-Ray Treatment CARDIOVASCULAR Angina pectoris Temporary myocardial ischemia, usually secondary to atherosclerosis Man of > 50 years with Cardiovascular risk factors Retrosternal, radiating to the shoulders, arms, neck, lower jaw or upper abdomen Normal OK IN ANGINA -hyper acute T waves(tall and symmetric) -ST elevation -significant Q waves (>40msec OR >1/3 QRS) -inverted T waves NORMAL -General measures -Antiplatelet therapy -B-blockers -Nitrates -CCB -ACE inhibitors -Invasive strategies Myocardial infarction Prolong ischemia >30 min Same as in angina, but >30 min Possible hemodynamic changes NORMAL Pericarditis Irritation of the parietal pleura adjacent to the pericardium Viral infection, Autoimmune disorders, post- myocardial infarction Sharp, knifelike pain, relieve when leaning forward Pericardial friction rub -Diffuse ST elevation -PR segment depression -upright T waves -isoelectric ST, flat or inverted T waves Cardiomegaly, rounded cardiac countour -treat underlying disease -high dose NSAIDs -colchicine rate of incessant/recurrent pericarditis Aortic dissection A splitting within the layers of the aortic wall Hypertension Marfan syndrome tearing chest pain, radiating to the neck, back or abdomen Aortic insufficiency murmur, Weak pulses normal Enlargement of the aortic arc Surgery PULMONARY
- 2. The Medical Beast Page 2 Pulmonary embolism Lodging of a blood clot in the pulmonary arterial tree Immobilization Post-operative Malignancy coagulopathy Sudden dyspnea, fever, chest pain 30% calf swelling And tenderness -Sinus tachycardia, -S1Q3T3 pattern -Hampton’s hump -westermark’s sign -atelectasis -elevation of hemidiaphram Oxygen, analgesics, acute AND long term anticoagulation, IV thrombolytic, ITT, IVC filter, thromboprophylaxis Pleural effusion Liquid in pleural space Pneumonia, TB, CHF, nephrotic syndrome Cough, Dyspnea, Pleuritic chest pain Dullness, decrease tactile fremitus/ breath sounds Dense opacification with concave meniscus Thoracocentesis, Treat underlying cause Pneumothorax Air in pleural space Previous trauma, emphysema Hyperresonance, diminished breath sounds/tactile fremitus Separation of visceral and parietal pleura Small (<20%): nothing Large: chest tube Treat underlying cause Pneumonia Lung Infection Dullness, bronchial breath sounds, crackles Lobar consolidation or interstitial pattern Antibiotics, IV fluids, O2 GASTROINTESTINAL AND OTHER Oesophageal spasm Muscle dysfunction of the esophageal muscle Retrosternal brutal squeezing pain Nitrates, CCB, anticholinergics. Esophageal myotomy Reflux esophagitis Inflammation of the esophageal mucosa by reflux of gastric acid Burning pain, increased when bending over, lying down Possible Hiatal hernia PPIs, antacids, H2-blockers Costochondritis variable Stabbing, sticking local pain Sterno-costal joint tenderness Possible erosion of sterno-costal joint NSAIDs