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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 pts 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 Tietzs 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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