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