APPROACH TO A PATIENT WITH CHEST PAIN DR JAYANTA PAUL 1 ST YEAR PGT, DEPT OF MEDICINE BURDWAN MEDICAL COLLEGE
APPROACH TO A PATIENT WITH
CHEST PAINDR JAYANTA PAUL
1ST YEAR PGT, DEPT OF MEDICINE
BURDWAN MEDICAL COLLEGE
• 5 Million emergency department visits• 2 million hospitalizations annually with cost
of more than $8 billion• Cardiac etiology found in less than one third• 2% of patients with acute MI are
unrecognized and discharged from the ED
Goals
1. Rapid recognition and management of true ACS2. Recognition of other life-threatening causes of
chest pain3. Minimize cost and hospitalization in patients
with chest pain of benign etiology.
PAIN IN THE CHEST BUT ORIGIN??
• HEART• LUNGS• OESOPHAGUS• MUSCULOSKELETAL STRUCTURES OF
THORAX NECK,OR SHOULDER• ABDOMEN• ANXIETY MANIFESTATION
LOCATION CENTRAL,DIFFUSE
PERIPHERALLOCALIZED
RADIATION JAW/NECK/SHOULDER/ OCCASIONALLY BACK
OTHER ORNO RADIATION
CHARACTER TIGHTSQUEEZINGCHOKING
SHARPSTABBINGCATCHING
PRECIPITATION EXERTIONEMOTION
SPONTANEOUSNOT RELATED TO EXERTIONPROVOKED BY POSTURE,RESPIRATION OR PALPATION
RELIEVINGFACTORS
RESTNITRATES
NOT RELIEVED BY RESTSLOW OR NO RESPONSE BY NITRATES
ASSOCIATED FEATURES
BREATHLESSNESS RESP; GIT,LOCOMOTOR, ORPSYCHOLOGICAL
ISCHEMIC CARDIAC PAIN V/S NON-CARDIAC PAIN
Cardiac causes of chest pain
angina1.
2. AMI
3. pericarditis
A 50 years old patient presented with retro sternal chest pain which radiates to the left arm, jaw, neck
case1
1.Exacerbation with ?2.Relived with ? 3.Fever ?4.Type of chest
pain ? 5.Precipitating
factors ?6. male/ female ?
Auscultatory finding
Clinical diagnosis ?
investigation
Cardiac cause
Clinical Spectrum of Acute Coronary Syndromes
Stable angina Unstableangina
Non-STE MI STE MI
Evidence of necrosis None Positive Positive
ECG early ST-segment depression
and/orT-wave inversion
ST-segment depression
and/or T-wave inversion
ST-segment elevation
ECG late No Q No Q Q develops
Respiratory causes of chest pain
1. Pulmonary embolism
2.Tension pneumothorax
3. pneumonia
A 30 years old patient presented with sudden onset right sided chest pain not radiates to the any other sites
Case 2
1.Predisposing factors ?
2.Fever ?3. types of
chest pain ?4.Other
associated symptoms ?
Auscultatory findings
Breath sounds
Clinical diagnosis ?
investigation
Respiratory cause
PULMONARY EMBOLISM
• RISK FACTORS FOR THROMBOEMBOLISM• CLINICAL FEATURES DEPEND ON SIZE • FAINTNESS OR COLLAPSE• CENTRAL CHEST PAIN• APPREHENSION• SEVERE DYSPNOEA• PLEURITIC PAIN• HAEMOPTYSIS
TENSION PNEUMOTHORAXDIAGNOSIS
Vascular causes of chest pain
1. Thoracic aortic dissection
2. Sickle cell anemia
A 33 years old woman during her pregnancy presented with severe sudden onset severe chest pain which radiates to the back between the shoulder baldes
case3
Character of pain : tearing or ripping sensation
Precipitating factors:
Hypertension Connective tissue disorder
Diagnosis ?
Vascular cause
AORTIC DISSECTIONPREDISPOSING FACTORS
• HTN• AORTIC ATHEROSCLEROSIS• NON-SPECIFIC AORTIC ANEURYSM• AORTIC COARCTATION• COLLAGEN DISORDERS MARFANS SYND,,,E D SYNDROME• FIBROMUSCULAR DYSPLASIA• PREVIOUS AORTIC SURGERY CABG AV REPLACEMENT • PREGNANCY(3RD, TRIMESTER)• TRAUMA• IATROGENIC
AORTIC DISSECTIONCLINICAL FEATURES
• TEARING PAIN• ABRUPT ONST• COLLAPSE• MARFAN`S SYNDROME• PT APPEARS TO BE IN SHOCK• BP---NORMAL OR reduced• ASYMMETRY OF PULSES• MI• PARAPLEGIA(SPINAL)• ACUTE ABDOMEN(MESENTERIC
CAELIAC)• RENAL FAILURE• ACUTE LIMB ISCHEMIA(LEGS)
GI causes of chest pain
1. Esophageal reflexes
2. Esophageal rupture
3. pancreatitis
4, Peptic ulcer
case4
A 30 years old patient presented with retro sternal & epigastric burning sensation not radiates to any other sites.
Pain most often exacerbated byalcohol, aspirin & foods
Pain is often relieved by antacids
Lying down , morning
Clinical diagnosis ?
Investigation ?
Gastrointestinal cause
Musculoskeletal causes of chest pain
1. costochondritis
2. trauma
case5
A 38 years old patient presented with chest pain for last 20 days , worsened with
On examination : local tenderness swelling , redness
present
+/-
Active and passive movement
Clinical diagnosis ? investigation
Musculoskeletal cause
Others
HERPES ZOSTER
psychological
Thank you