Chest Pain Etiology May be benign or life threatening
e.g : 48y , off/on chest pain for last few weeks so eti es e e!ertion so eti es e rest , na"sea , no past e#.$! % refl"! ost likely i & b"t intial test is EC' ( ).* : Menstr"ation an# estrogen keep Coronary health +o e,al"ation sho"l# e!cl"#e i ost serio"s con#ition -st : Co on .isk /actors : 0 $1) 0 2M 0 + oking 0 $yper3ipi#e ia 0 4,e fa ily $! 0 Men 5 46 y, 7o en 5 66y
$istory
$! taking is ore "sef"l than physical e!a . 8s it co on to fin# patient nor al in e!a ination. e.g : 96y :, e!ertion chest pain % ost likely ische ic an# can #ie by heart attack ( ost
-02"ration: -; to <; in not sec. or ho"rs =0>"ality: #"ll , sore , s?"ee@ing , thightness , hea,ness , Preas"re % not sharp,knife,point like by A6B ( <03ocation: +"bsternal by A6B %for s"re not in .t.si#e , ostly not in 3t.si#e ( 40.a#iation: to neck , ar Cf absent not ische ia 60/re?"ancy: D0Precipitating /actors: E e E!ertion , .elie,e# by .est 908ssociate# +y p: shortness of breath , sweating
Clinical Pearls
Cnf.wall ische ia E ,egal refle!es inf.wall press C #iaphrag ca"sing irritation 3= : )a"sea , Fo iting *ra#ycar#ia , $ypotension CtGs calle# Harisch *e@ol# .efle! :0 inf wall infla C percar#i" ca"sing E ,egal tone F2 I$. Cf Chest pain associate# e position , ple"rtic %respiration( , ten#erness , palpation ostly e!cl"#e car#iac ca"se. Chest Pain of ische ia or esophageal spas .elie,e# by nitroglycerine *"t Chest Pain of 'E.2 7orse by nitroglycerine
Physical E!a
1acypnea , 1achycar#ia not specific b"t always present e PE *P #ifference of J =; $g % ( ar s is present in 9;B Kf cases of 8ortic 2issection 8"ssc"ltaion :
-0 + =
%8=P=( +low cont.of .t.,ent %2elay clos"re of p"l .,al,e( I 7i#e +plit += Ca"ses : .*** P"l .$1) P"l .+tenosis .F$ +low cont.of 3t.,ent %P= ca es before 8= ( I Para#o!ical split += 3*** $1) 8ortic +tenosis 3F$
).*: /i!e# +plit + = 8trial +eptal 2efect
=0 + 4
CtGs sign for 3F$ % atrial systole ( ische ic is stiff, infle!ible % 7e see +4 in patient e hypertension for =;y 7e #o )othing no special therapy ( yocar#i"
<0 + <
% .api# /illing of ,entricles( 8c"te p"l .e#e a , C$/ , Fol" e o,erloa# )ee# to E #i"retics , 8CEC , *.blocker. 40 8. , M.
Cn,est EC'
0 Cs best intial test % chest pain , +1 ele,ation start therapy ( En@y 0 0 0 0 0 0 es % CL0M* , 1roponin ( +pecific for MC % 1roponin E in ./( 2iff % ( "nstable angina , MC CL0M* takes 4 M D h to ele,ate reach peak -= M =4h so C canGt "se 1P8 before -=h last for < M 4 #ays 2 for reinfarction )or al CL0M* 4 E 1roponin N inor yocar#ial 2a age ECL0M* 4 E 1roponin N ac"te yocar# Cnfarction
).*:
8C+
% "nstable angina , MC ( Csche ic pain b"t C #onGt know if itGs infarction or not
Cf /o"n# +1 ele,ation Jin = lea#s
+1 #epression 1 wa,e in,ersion )or al
I )o 1P8
% if CC,CCC,aF/ is ac"te infarcion( +tart therapy I 01hro bolytics %1P8( 08ngioplasty %PCC(
2ifferntial 2iagnosis
Costochon#ritis 'E.2
Chest wall ten#erness E by palpitation *a# taste,co"gh, horseness .elief by PPCs Epigastric pain E by eating Cf " ha,e non ische ic chest pain ostly consi#er 'E.2
Most co on ca"se of epigast.pain is non "lcer #yspepsia %not gastritis , "lcer, pancertitis, cancer(
PO
2O 8ortic #issection
Epigastric pain I by eating .a#iating pain in the back % ( scap"le "ne?"al p"lse % ( ar s
En#oscopy 7i#ene# e#iastin" in CP. then #o 1EE,C1,M.C EC' shows +1 ele,ation, P. #epression
Pericar#itis
Mitral ,al,e prolapse PE
Ple"rtic, positional%Iby lying forwor#,Eby lying back( Cf no response to )+8C2 8fter = #ays start steroi# 8typical pain in yo"ng e palpation, panic +"##en onset, EC': +-><1< tachycar#ia,tacypnea, C1,p"l angio, hypo!ia, ple"ritic pain, F/> scan he optysis
Pne" othora!
+harp ple"ritic pain, tracheal #e,iation, Ibreath so"n#s +igns of .+$/ +harp ple"ritic pain e r"b
CP.
P"l .$1) Ple"ritis
pne" onia
Co"gh, sp"t"
Ca"ses of ple"ritic pain: 0PE 0P1P 0pericar#itis 0ple"ritis 0pne" onia CP.
