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Chest Pain Presentation
Chest Pain Presentation
Chest Pain Presentation
MEDICAL INTERNSHIP
IM WARD CASE
PRESENTATION
CHEST PAIN
JUAN G RAMIREZ, MI
CAMILLE DEL PILAR, MI
HISTORY OF PRESENT
ILLNES
72 y/o M with PMHx back and cervical pain.
No meds.
07/17/15- Epigastric Pain.
L:middle
chest
07/18/15- 1ST ER visit: Troponin NEG
of
the
I: 6 of 10
Q: oppressive
O: 2 days ago
R: Both shoulders
A/A: none
A: Epigastric pain
EKG NEG
RX NEG
07/19/15- 2ND ER visit: Chest Pain
No nausea, no vomits
PHYSICHAL
EXAMINATION
GEN: AAOx3, Mild Distress, Antialgic position Afebrile
VS: RR= , HR= , BP=
, Temp=
HEEENT: WNL.
NECK: mild discomfort on movement.
CHEST: CTAx2, Parasternal superficial tenderness(2 nd
day).
HEART: RRR, NEW Murrmur(3rd day), no Galop, no Rubs.
Abdomen: BS+, Mild Epigastric Tenderness, no masses.
Extremities: WNL.
Neuro: WNL.
LABORATORIES
TROPONIN I- NEG x30.12 0.21
CK-MB: neg
.
Chest X Ray
DIFFERENTIAL
DIAGNOSIS
Commons:
-VS-
Acute coronary
syndrome
Stable angina
Pulmonary embolism
Pneumonia
Viral pleuritis
GORD
Costochondritis
Anxiety/panic
disorder
Uncommons:
Pericarditis
Cardiac tamponade
Aortic dissection
Aortic stenosis
Mitral valve prolapse
Pneumothorax
Pulmonary hypertension
Peptic ulcer disease
Oesophageal spasm
Acute cholecystitis
Pancreatitis
Herpes zoster
Gastritis
ACS
1st-TEST
ECG:ST-elevation MI (STEMI): ST-segment elevation >1 mm in 2
anatomically contiguous leads or new left bundle-branch block; nonST-elevation MI (NSTEMI) or unstable angina: non-specific; STsegment depression or T-wave inversion
cardiac enzymes:elevated in STEMI and NSTEMI; not elevated in
unstable angina
CXR:normal or signs of heart failure, such as increased alveolar
markings.
2st- Tests
coronary angiography:STEMI: critical occlusion of a coronary
artery; NSTEMI and unstable angina: evidence of coronary artery
narrowing
BNP:>99th percentile of normal
Stable angina
HPI: central chest pressure, squeezing, or heaviness;
Stable angina
1st test:
ECG:no acute changes; may have evidence of previous
infarction, such as Q waves
CXR:normal or cardiomegaly
cardiac biomarkers:not elevated
Other tests:
stress testing:1 mm of horizontal or down-sloping ST-
Pulmonary embolism
HPI: sharp and pleuritic in nature; shortness of breath;
PE
1st test
ECG:sinus tachycardia; presence of S1, Q3, and T3
D-dimer:non-specific if positive; PE excluded if result negative in
patients with low probability of having a PE
CXR:decreased perfusion in a segment of pulmonary vasculature
(Westermark sign); presence of pleural effusion
CT pulmonary angiography: identification of thrombus in the
pulmonary circulation
Others Test:
echocardiography:acute right ventricular dilation or hypokinesis
V/Q scan :V/Q mismatch
pulmonary angiography: identification of thrombus in the
pulmonary circulation
Pneumonia
History productive or dry cough, fever, pleuritic pain associated with
Other tests:
WBC count:elevated with left shift (increased neutrophil count)
sputum culture:may reveal culprit organisms, but not sensitive or
specificMore
blood culture:may reveal culprit organisms, but not sensitive or
specific
Viral pleuritis
History prodrome of viral illness (myalgias, malaise,
Other tests :
FBC:normal, or leukocytosis with lymphocytic
predominance
GERD
History retrosternal burning with eating large or fatty
proton-pump inhibitors
Other tests:
Oesophagogastroduodenoscopy: oesophageal
inflammation or erosions
oesophageal pH monitoring: persistently low pH
(<4) may indicate reflux disease
Costochondritis
History focal chest wall pain, may have known
malignacies)
Other tests
Other tests:
CXR:normal
HADS (hospital anxiety and depression scale)
score:score >11
Consult to Cadiology
Pt.
Risk
factors
Age,
Hypercholesterolemia,
ACS Dx. Excluded
Patient presentation is unlikely due to a
cardiac event, pain description does not
indicate a cardiovascular etiology. Diagnostic
evaluations are negative. The only sugestive
risk factors are the age, cholesterol levels and
HTN.
Management
Severe pain (due to costochondritis, Tietze's syndrome,
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