Medical - Year 4 - Seminar - Approach to Chest Pain

8/6/2019 Medical - Year 4 - Seminar - Approach to Chest Pain

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APPROACH TO CHESTPAIN

Investigation &Management

Mohd Hafis Zul Arif Bin Awang01201005 0476

(BMSc), 4th Year MBBS IMS:MSU


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Differential Diagnoses

CARDIOVASCULAR

Angina

Myocardial ischemia

or infarction Aortic dissection

Pericarditis

Tamponade

GASTROINTESTINAL

Esophagealperforation

Reflux esophagitis Gastritis, peptic ulcer

disease

Esophageal spasm

Hiatus hernia

Pancreatitis

Biliary tract disease


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PULMONARY

Pneumonia

Pulmonary embolism

Pneumothorax

Hemothorax

Pleuritis/Serositis

MUSCULOSKELETAL

Chest wall injuries

Costochondritis

Secondary tumor ofthe rib

Shingles (HerpesZoster)

Fibromyalgia


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PSYCHOLOGICAL

Depression

Panic disorder

Anxiety

Depression

Somatoform disorders


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Investigations

General Blood test Complete blood count Electrolytes and renal

function (creatinine) Liver enzymes D-dimer Serum amylase Cardiac markers

Troponin I or T Creatine kinase (CK-MB) Chest Xray ECG

Specific

V/Q scan

Pulmonary

angiography CT aortography

Upper GI endoscopy

Esophageal

manometry


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Myocardial Ischemia / Infarction Aortic Dissection

Pulmonary Embolism

Pneumothorax

Others


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MyocardialIschemia/Infarction

Investigation EKG CXR to look for signs of congestive heart

failure Cardiac enzymes: CK(will begin to rise 6 hours after infarct and

remain elevated for 24-48 hours),Troponin (will begin to rise 12 hours after infarct

and remain elevated for 2 weeks). Exercise-stress test, dobutamine stress

echo, myocardial perfusion scan: useful tolook for inducible ischemia if unsure

Coronary angiography: gold-standard


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12 Lead EKG

- Look for ST segment elevation (atleast

1mm in two contiguous leads)- Look for ST segment depression

- Look for T wave inversions

- Look for Q waves- Look for new LBBB

- Always compare to old EKGs


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Morphine for pain Oxygen if hypoxic Nitro spray/drip for pain Aspirin

Lasix if in congestive heart failure Inotropes if in cardiogenic shock Streptokinase (thrombolysis-TPA or TNK

more commonly used)

Anticoagulation Also, think of beta-blockers (reduce heart rate and

contractility but beware of worsening of CHF). Statinsand ACE-inhibitors should be added as indicated.

Primary angioplasty may be indicated.

Management


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Aortic Dissection

Investigation CXR: Look for widened mediastinum

CT Scan: Angiography

TEE


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Management

Antihypertensive therapyo Start with beta blockers (esmolol, labetalol)o Combined with vasodilators (nitroprusside) if

further BP control is needed ONLY afterhave achieved HR control with beta blockers

If ascending dissection: surgery

If descending: may be able to medically

manage


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Pulmonary Embolism

Investigation

ECG:

- Sinus tachycardia most common- Often see nonspecific abnormalities

- Look for S1Q3T3 (S wave in lead I, Q

wave in lead III, inverted T wave inlead III)


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Pulmonary Embolism

Chest X-ray- Normal in 25% of cases- Often nonspecific findings

- Hamptons hump: triangular pleural baseddensity with apex pointed towards hilum.Sign of pulmonary infarction.

- Westermarks sign: dilation of pulmonaryvessels proximal to embolism and collapse

distal.- Pallas sign: a prominent right descending

pulmonary artery.


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Westermark Sign,is a sign that

represents a focusof oligemia(vasoconstriction)seen distal to apulmonaryembolus.

The sign resultsfrom acombination of:(1) the dilation ofthe pulmonary

arteries proximalto the embolusand(2) the collapse ofthe distalvasculature

creating the


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Pulmonary Embolism

Other Investigation

ABG - Look for abnormalPaO2 ,PaCO2

Increased A-a gradient

D-dimer - elevated in PE. Notspecific

Pulmonary angiography - GoldStandard

V/Q Scan

Echo - if large embolus, can see

signs of right-sided compromise

Management

Anticoagulation - initiate Heparinfollowed by coumadin.

Fibrinolytic / Thrombolysis Therapy.

Supportive treatment with oxygen,and fluids.


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Pneumothorax

Investigation CXR: fine line of visceral pleural

detached from parietal pleura seenon ipsilateral side

o In large pneumoathoraces,

mediastinal shift and contralateralcompression of lung can be seen


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Pneumothorax

Management

Watchful wait for small pneumothoraces repeat CXR

Chest tube insertion for large, hemodynamicallyunstable pneumothoraces

In emergent situation, insert large bore needle in 2ndICS, midclavicular line, followed then by chest tubeinsertion.

Give oxygen: Increases pleural air absorption


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Others Management

Shingles

Antivirals - reduceduration of symptoms.May also reduceincidence ofpostherpatic neuralgia.

+/- corticosteroids -may reduce

inflammation Analgesia

Musculoskeletal Pain

Analgesia (NSAIDs)


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Others Management

Esophageal Perforation

Diagnosis

CXR: May see pleural

effusion (usually onleft). Also may seesubcutaneousemphysema,

pneumomediastinum,pneumothorax.

CT chest

Esophagram

Treatment

Broad spectrum

Antibiotics Immediate surgical

consultation


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Others Management

Psychological

Diagnosis of exclusion

Psychiatric evaluation


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THANK YOU

Documents

Medical - Year 4 - Seminar - Approach to Chest Pain