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 life- threatening 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 in- order 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 the changes seen.  What 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 how you will manage this patient.  What 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 the findings on the CXR and ECG.  What 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?