Chestpain Seminar03 091025004921 Phpapp02

Case 2-Chest PainAlifah & LiyanaFaculty of medicineUiTM,Malaysia

HistoryMdm. Xx, 60 y.o, chinese lady known case of HPT and DM for 10 years.Complaint of chest pain on the day of admission.Site : CentralNature : TightnessRadiation : jaw and left armDuration : 20 minutesAggravating factor : -Relieving factor : GTN ( KK)Associated symptom : nausea, sweating, dyspnoea,

Past Medical HistoryDM , HT 10 years

Surgical HistoryNil

Drug History For HT & DM

Allergy Nil

Family History+ve hx of HT, DM, heart problem

Social HistorySmoker (5sticks/day) Occasional drinker

Diet history- High fat food

PHYSICAL EXAMINATIONVital Signs:

BP:135/95 mmHgHR:92 beats/minute (regular rhythm and volume)RR: 22 breaths/minute

General examination- obese

Cardiovascular systemInspection: On inspection, there is no deformity, no dilated vein, no surgical scar, and no visible pulsation.

Palpation:The apex beat is not palpable. There was no parasternal heave. Thrills were also absent.

Auscultation:S1 and S2 were heard. There was no radiation, no murmur, no rubs and no additional sounds. S3 and S4 were not heard. There was no carotid bruit present. The 1st and 2nd maneuver (mitral stenosis and aortic regurgitation) reveals no significants findings.

Provisional diagnosisNon ST elevation myocardial infarction (NSTEMI) / unstable angina

History :

Central chest tightness :Radiated to jaw & left arm20 minutes Relieved by GTNAssociated with : nausea, sweating, dyspnoeaKnown case of DM & HT ( 10 years )+ve family hx of heart problemSmoker ( 20 years)fat food diet

PE : -obese

Differential Diagnosis

1. Acute myocardial infarctionPoints to support : Points to against :ECG : ST segment depressionRelieved by GTNDuration : 20 minutes

2. Aortic dissectionPoints to support : severe, sudden chest painHistory of HT & DMPoints to against :Chest Pain : tightness, not radiate to the backNo syncopeCXR : no boarding of upper mediasternal & distortion of aortic knuckle, no right sided pleural effusion & left ventricular hypertrophy

Pulmonary embolismPros:chest pain associated with shortness of breathCons:no hemoptysis and no risk factor ofhyper-coagulability like prolong bedrest.Pericarditis Pros:the patient present with chest painCons:the pain not aggravated by changes inposture like leaning forward.

investigationGeneral :

FBC, BUSE : no significant findingPT, PTT : normalCXR : normal ( No cardiomegaly, perihilar haziness and lung fields were clear)

Cardiac enzymes elevation of :Troponin T CKMBLipid Profile

LIPIDVALUENORMAL RANGEREMARKSTotal cholesterol6.6

ECGST segment depressionT inversion

Final diagnosisNon ST elevation myocardial infarction (NSTEMI)

Points to support :

Central chest tightness :Radiated to jaw & left arm20 minutes Relieved by GTNAssociated with : nausea, sweating, dyspnoeaKnown case of DM & HT ( 10 years )+ve family hx of heart problemSmoker ( 20 years)fat food diet

PE : overweight

IV

Lipid profile : increase LDL & total cholesterol

Cardiac enzyme :Troponin T & CKMB

ECG :ST segment depression & Tinversion

Management of acute coronary syndrome ( NSTEMI)

Criteria for high & low for death or MIHigh riskECG abnormalities

Dynamic ST segment changes > 0.05 mV, particularly ST segment depression Transient ST segment elevationT wave inversion > 0.2 mVPathological Q waveBundle branch blockSustain Ventricular tachycardia

Elevated Troponin levelLow RiskNo recurrence of chest pain within the observational periodNo ST segment depression or elevation but rather negative T wave, flat T wave or normal ECGWithout elevation of Troponin or other biomarker of cardiac injury

High RiskLow risk

Management Post hospitalization

Medical therapy ( compliance )Life-style modification: Diet : highly oily fish, fruit, vegetable, fiber & low fats: Exercise : Regular daily exercise: Avoid air travel for 2 months: Reduce & stop smoking- Follow up ( after 3 & 5 weeks )

referencesSarawak Handbook of medical emergenciesOxford Handbook of clinical medicineDavidsons, Principle & practice of medicine