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APPROACH TO CHEST PAIN

Etiology . AnginaUnstable Angina Acute MIAortic StenosisPericarditisAortic Dissection Pul.EmbolismPul.HTN. PneumoniaPleuritisSpontaneous PneumothoraxEsophageal RefluxEsophageal SpasmPeptic ulcerHerpes ZosterMusculoskeletal dsGall bladder ds. GOALS ? EVALUATION OF PATIENT WITH CHEST

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APPROACH TO CHEST PAIN

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    1. APPROACH TO CHEST PAIN Dr.Vemuri Chaitanya

    2. Etiology Angina Unstable Angina Acute MI Aortic Stenosis Pericarditis Aortic Dissection Pul.Embolism Pul.HTN Pneumonia Pleuritis Spontaneous Pneumothorax Esophageal Reflux Esophageal Spasm Peptic ulcer Herpes Zoster Musculoskeletal ds Gall bladder ds

    3. GOALS – EVALUATION OF PATIENT WITH CHEST PAIN Determining the diagnosis Assessing safety of the immediate management plan especially in Acute chest discomfort.

    4. Acute Chest Pain Assess pt’s respiratory & hemodynamic status If either is compromised – initially focus on stabilizing pt before diagnostic evaluation. If pt does not require emergent intervention , -- focussed history , physical examination, lab investigations.

    5. History Quality of pain chest discomfort / heaviness/pressure/burning sensation -- Angina , Unstable angina, Acute MI Lancinating / sharp / knife like / stabbing – Herpes Zoster , Pleuritis , Pneumonia , Pericarditis , Pulmonary embolism Tearing / ripping – Aortic Dissection Burning – GERD, Peptic ulcer, gall bladder ds ,herpes zoster Variable - Psychologial

    6. Location & Radiation Retrosternal , often radiating to left shoulder, neck , jaw- Angina , Unstable angina , Acute MI , Aortic Stenosis Localised to small, specific area pointed with finger – unlikely to be true angina Dermatomal – Herpes Zoster, Cervical disc ds Radiating to back – Aortic dissection , expanding thoracic aortic aneurysm,ruptured peptic ulcer, pancreatitis

    7. Location & Radiation Retrosternal / towards cardiac apex- Pericarditis Lateral – Pul.embolism Substernal – Pul.HTN, Esophageal reflux U/L , localised – Pneumonia Epigastric – Peptic ulcer Epigastric&Rt upper quadrant –gall bladder disease. Anterior chest musculoskeletal – Tietz’s syndrome

    8. Duration , Frequency , Recurrence >2 & <10 min , on exertion , exposure to cold, heavy meals – Angina 10 – 20 min , unpredictable , on exertion or at rest – Unstable Angina Variable > 30 min , not relieved by nitrates – Acute MI Recurrent episodes as of angina – AS Abrupt unrelenting pain – Aortic dissection Hours – days , episodic - Pericarditis

    9. Duration , Frequency , Recurrence Abrupt , several min – few hrs – pul.embolism Variable –, pul.HTN Herpes zoster , musculoskeltal pain , emotional , psychiatric Periodic – peptic ulcer 10 – 60 min - GERD

    10. Modifying Factors Anginal pain – ppt by exertion , relieved by rest and nitrates Emotional upset , anxiety , exposure to cold – angina Pain changes in intensity with change in body position – musculoskeletal pain , pericarditis( abates after leaning forward )

    11. Associated Symptoms Chest pain d/t ischemia – dyspnea, nausea, vomiting, diaphoresis, palpitations Late peaking systolic murmur radiating to carotids – AS Pericardial friction rub – pericarditis Loss of peripheral pulse , EDM , pericardial rub , tamponade – aortic dissection

    12. Associated Symptoms Dyspnea – pleuritis , pneumonia , pul.embolism( tachypnea, tachycardia, hypotension ) Relieved by antacids – GERD, peptic ulcer Worsened by postprandial recumbency – GERD Aggravated by movement – musculoskeletal , pleuritis Cardiac risk factors : smoking , hyperlipidemia , HTN , DM , F/H of CAD, Obesity, Postmenopausal

    13. Physical Examination Vital signs – BP – Hyper/hypotensive ? equal / unequal in limbs RR – Tachypneic ? HR – Tachycardia ? pulsus paradoxus General appearance , head & neck Lungs CVS Abdomen Extremities – edema – u/l or b/l Skin – vesicles – herpes zoster ? Neurological – mood ?

    14. Lab Investigations Routine – CBC, LFT, S.Electrolytes , S.amylase & lipase Cardiac enzymes – CK –MB , Trop T & I ECG CXR PA View TMT V/Q Scan Chest CT , TEE , MRI – Aortic dissection Spiral CT – Pul.embolism

    15. Treatment Angina – NTG , other nitrates , rest Unstable angina – bed rest , antiplatelet therapy , beta blocker , LMW Heparin , PCI , Acute MI early - Aspirin , Morphine, acute reperfusion(thrombolytics,PCI) , Anticoagulants late – life style modification , anti platelet agents, Statins , beta blocker, ACEI , Rehabilitation Pericarditis – aspirin , indomethacin , corticosteroids, antimicrobials Aortic dissection – pain control & BP- Sod. Nit.prusside type A – Surgical repair type B - Medically / surgically Pul embolism – heparin

    16. Treatment Pneumonia – antibiotics GERD – PPI Herpes Zoster – acyclovir Psychological – anti depressants , anxiolytics

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