Chest Pain PDF

Chest Pain  Chest pain Chest pain may have no serious cause , but always think ( could this be a myocardial infraction (M.I) , pulmonary embolism (P.E) , dissecting aortic aneurysm , or pericarditis ). Its important to distinguish cardiac pain from other causes of pain , depend...

Chest Pain  Chest pain Chest pain may have no serious cause , but always think ( could this be a myocardial infraction (M.I) , pulmonary embolism (P.E) , dissecting aortic aneurysm , or pericarditis ). Its important to distinguish cardiac pain from other causes of pain , depending on careful history and physical examination , and lab findings. Also imaging techniques sometimes help in narrowing the differentional diagnosis.  Causes of chest pain : 1.Anxiety / emotional 2. Cardiac causes : a) Myocardial ischemia(angina) b) Myocardial infraction (M.I) c) Aortic stenosis d) Aortic aneurysm/aortic dissection e) Pericarditis /Myocarditis f) Mitral valve prolapse 3.Lung and pleura causes : a) Bronchospasm b) Tracheitis c ) Pneumonia  d) Pulmonary infraction / pulmonary embolism (P.E) e) Pnemothorax f) T.B g) Malignancy h) Connective tissue diseases 4.GIT causes a. Oesophagitis b. Oesophageal spasm c. Mallory-Wiess syndrom 5. Musculoskeletal disorders : a) Arthritis b) Costochondritis c ) Intercostal muscle injury e) Rib fracture or injury f ) Epidemic myalgia (Bornholm disease ): by Coxsackie viral infection 6. Neurological disorders : a) Prolapsed intervertebral disc b) Herpes zoster c) Thoracic outlet syndrom.  Any history of a ( pain ) should be taken by SOCRATES questions : - S = Site O = Onset C = character R = Radiation A = Associated T = Timing / duration E = Exacerbated and relieving factors S = Severity  Analysis of chest pain according to ( SOCRATES ) questions :- ❖ Site : Cardiac pain is typically located in the center of the chest, because of the derivation of the nerve supply of the heart and mediastinum. ❖ Onset : M.I develops gradually (take several minutes or even longer) , also angina develops gradually depending on the intensity of exertion. The pain of P.E , pnemothorax and aortic dissection is very sudden. ❖ Character : - Cardiac pain is constricting , dull , chocking , or heavy pain , and its described by the patient as a squeezing , aching , burning. Sometimes cardiac pain is felt as a breathlessness or a discomfort sensation rather than pain. - Pain due to pleura or pericardium is sharp, stabbing, pricking ,or knife- like pain that increase with coughing, inspiration and movement. - Aortic dissection result in tearing instantaneous pain. - Anxiety and esophageal pain may result in constricting pain. Radiation : - Ischemic cardiac pain is typically radiates to the jaw , neck , either or both upper sometimes lower arms. Occasionally the cardiac pain may be experience only in the sites of radiation or in the back.Epigastric pain could be a cardiac in origin. - Aortic dissection pain is tearing, instantaneous interscapular pain , and it could be retrostrenal. - Pain over the left anterior chest and radiates laterally is unlikely to be cardiac in origin ( pleural,pericardium,lung,musculoskeletal problems and anxiety). Associated symptoms : - Autonomic symptoms :nausea,vomiting,pallor, and sweating. These symptoms are typically seen in patient with M.I. massive P.E and aortic dissection. - Dyspnea : result from left ventricular ischemia ,which results in pulmonary congestion ; P.E ,lung and pleural disorders and anxiety also result in dyspnea. - GIT symptoms : due to esophagitis,esophageal reflux, peptic ulcer, and biliary disease. These will help in distinguish of non-cardiac chest pain - Chest pain associated with tenderness is due to self –limiting Tietze syndrome Radiculopathy ❖ Timing / duration : prolong chest pain (>30 min.) suggest M.I ❖ Exacerbating (precipitating) and Relieving factors : Exacerbating - Angina pain is occurred during (not after) exercise; also cardiac pain is occurred with palpitation ,exposure to cold, after heavy meal and emotional stress. - Pain brought by meals, hot drink, alcohol or lying flat is resulted from esophageal spasm or diseases. - pain brought by breathing, coughing, or movement is due to pericardial/pleural disorders. Relieving -Angina pain is relieved by GTN( glyceryl triniatres ) within min.s , usually less than 5 min.s - Esophageal spasm can be relieved by GTN , but more slowly. - Chest pain due GIT causes is relived by antacid. - Pericardial pain is relived by bending forward  Management of patient with chest pain : 1. If the patient is acutely ill , admit to the hospital. 2. Check BP(blood pressure) in both arms , PR (pulse rate) , JVP(jugular venous pressure) , heart sounds and legs for DVT. 3. Give O2 by mask. 4. I.V line 5. Relive pain (e.g. morphine 5-10 mg I.V slowly+ antiemetic). 6. 12 –leads ECG Cardiac monitoring. 7. Cardiac monitoring. 8. Chest X- ray 9. Arterial blood gas analysis.