Approach to Patient with Dyspnea & Chest Pain PDF

APPROACH TO PATIENT WITH DYSPNEA & CHEST PAIN Presented By : Mustafa Ibrahim Osama Mahmoud Hagar  2 ILOs Cau...

APPROACH TO PATIENT WITH DYSPNEA & CHEST PAIN Presented By : Mustafa Ibrahim Osama Mahmoud Hagar  2 ILOs Causes of chest pain. Types and causes of dyspnea. History,examination and History,examination and investigations investigations Treatment options for patient with Treatment plan for patient with dyspnea chest pain  3 DYS: DIFFICULT, PAINFUL PNEA: BREATH  4 Definition of dyspnea Dyspnea,(shortness of breath) is the feeling that you can’t get enough air into your lungs. It might feel like your chest is tight, you’re gasping for air or you’re working harder to breathe. Heart and lung conditions are common causes of dyspnea. It is a common symptom impacting millions of people and maybe the primary manifestation respiratory, cardiac, neuromuscular, psychogenic, systemic illness, or a combination of these. Dyspnea can be either acute or chronic;m acute occurs over hours to days and chronic for more than 4 to 8 weeks  5 Types of dyspnea  6 Causes of dyspnea 1-Cardiac causes:  6 Causes of dyspnea 1-Cardiac causes: CHF CAD Cardiac tamponade Cardiomyopathy Arrhythmia Pericarditis  7 Causes of dyspnea 2-Respiratory causes:  7 Causes of dyspnea 2-Respiratory causes: Asthma COPD Pulmonary embolism Pneumonia Pneumothorax  8 Causes of dyspnea 3-Non Cardiac or Pulmonary causes:  8 Causes of dyspnea 3-Non Cardiac or Pulmonary causes: Normal symptom of heavy exertion Normal pregnancy around(2/3rd) Trauma Neuromuscular disorders Obesity Chemical exposure Functional (anxiety, panic disorders, hyperventilation) 9 10 11 12 13  14 History taking Risk Factors of cardiac diseases: SHADES OF DM Smoking Hypertension Obesity Diabetes milletus Age Family history Dyslipidemia Erectile dysfunction?? Stroke  15 History taking Risk Factors of respiratory diseases: Smoking Occupational exposure: sillica or coal Allergen exposure: birds or dust  16 History taking Important questions to ask: When did the shortness of breath start? Have you had shortness of breath in the past? Do you have a diagnosis of COPD or asthma? Are you short of breath at rest or only during exertion? Have you had any other symptoms such as a cough, fever, or wheeze? Have you coughed up any blood? Is it associated with chest pain?  17 Examination What should I look for in a targeted examination? Blood pressure ⁠Pulse (tachycardiac, bradycardic or irregular). Cardiac auscultation (murmurs, gallop or pericardial rub) Chest auscultation (fine basal crepitations )  18 Examination Important signs: Pallor (may suggest that anemia or bleeding is the cause of dyspnea). Fever (may suggest presence of pneumonia that causes dyspnea). Cyanosis (usually suggests lung disease, but may occur in severe hypoxia ).  4 Investigations 1. ECG 2. ABG 3. Chest X ray  4 Investigations ECG FINDINGS Tachycardia Bradycardia ST elevation,depression,or biphasic phase Long QT  4 Investigations ARTERIAL BLOOD GASES Bicarbonate and Lactate Po2 Pco2 Hematocrit  4 Investigations CHEST X-RAY Cardiomegaly Pulmonary venous congestion pulmonary hypertension wide aortic window pneumonic patch  4 Grading of dyspnea  4 Treatment Treatment will depend on the cause of the problem: A person short of breath due to overexertion : will probably get their breath back once they stop and relax.  4 Treatment Treatment will depend on the cause of the problem: In more severe cases, a person may require supplemental oxygen. Those with asthma or COPD may have an inhaled rescue bronchodilator to use when necessary. However, not everyone with shortness of breath will have low blood oxygen levels.  4 Treatment Treatment will depend on the cause of the problem: For those with chronic conditions, such as COPD, a healthcare professional will work with the individual to help them breathe more easily. This will involve developing a treatment plan that helps to prevent acute episodes and slow down the progression of the overall disease.  4 Treatment Medications: In cases of dyspnea due to asthma, it typically responds well to medications such as bronchodilators and steroids When it is due to an infection such as bacterial pneumonia, antibiotics can bring relief. Other medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs), and anti-anxiety drugs, can also be effective.  4 Chest pain Cardiac causes: Angina Pectoris: Chest pain due to inadequate blood flow to the heart muscle. Myocardial Infarction: Heart attack resulting from a blockage in the coronary arteries. Pericarditis: Inflammation of the pericardium (the heart's outer lining). Myocarditis: Inflammation of the heart muscle. Aortic Dissection: A tear in the aorta that can cause severe pain. Arrhythmias: Abnormal heart rhythms that may cause pain or discomfort. Coronary Artery Spasm: Temporary tightening of the muscles in the artery walls.  4 Chest pain Non cardiac causes: Gastroesophageal Reflux Disease (GERD): Acid reflux can cause burning chest pain. Musculoskeletal Pain: Strain or injury to muscles or ribs. Pulmonary Conditions: Pneumonia, pleuritis, or pulmonary embolism can cause chest discomfort. Anxiety or Panic Attacks: Can lead to chest tightness or pain. Esophageal Disorders: Conditions like esophageal spasm or achalasia. Shingles: A viral infection that can cause localized pain in the chest. Costochondritis: Inflammation of the cartilage connecting the ribs to the breastbone.  4 Chest pain Life-threatening causes: Myocardial Infarction (Heart Attack): Blockage of blood flow to the heart muscle. Aortic Dissection: A tear in the aorta that can lead to massive internal bleeding. Pulmonary Embolism: A blood clot in the lungs that can cause severe respiratory distress and cardiovascular collapse. Tension Pneumothorax: Accumulation of air in the pleural space leading to lung collapse and compromised circulation. Cardiac Tamponade: Accumulation of fluid in the pericardial sac that compresses the heart. Severe Arrhythmias: Life-threatening irregular heartbeats that can result in sudden cardiac arrest. Esophageal Rupture: A tear in the esophagus that can lead to severe internal bleeding and infection. Prompt recognition and treatment of these conditions are critical for survival.  4 Chest pain Analysis of chest pain SOCRATES S: Site: Where is the pain located? O: Onset: When did the pain start? C: Character: What type of pain is it (e.g., sharp, dull, burning)? R: Radiation: Does the pain spread to other areas? A: Associated features: Are there other symptoms related to the pain? T: Time course: How long has the pain been present? E: Exacerbating or alleviating factors: What makes the pain worse or better? S: Severity: How intense is the pain?  4 Chest pain Analysis of chest pain SITE Central: ACS, pericarditis, pleurisy left side: ACS , pericarditis, pleurisy right side: ACS, pleurisy Infra mammary: neuroginic > Herpes Zoster, Cervical ONSET Abrupt onset with greatest intensity at start: Aortic dissection Pneumothorax, PE Gradual: ischemic, ACS, peptic causes  4 Chest pain Analysis of chest pain CHARACTER Sharp/stabbing: ACS, Pericarditis, Pleuritis, Aortic dissection, Heartburn, strained muscle Squeezing/tightness/pressure: ACS, Angina, Panic Attack Tearing: Aortic dissection RADIATION Jaw: ACS neck: retrosternal goiter, ACS left shoulder: ACS back : duodenal ulcer, perforated ulcer intrascapular area: aortic dissection  4 Chest pain Analysis of chest pain Associated symptoms Fevers, chills, URI symptoms, productive cough: Pneumonia Nausea, vomiting, diaphoresis: MI Shortness of breath: PE, PTX, MI, Pneumonia, COPD/Asthma Asymmetric leg swelling: DVT New onset neurologic findings or limb ischemia: Aortic dissection Pain with swallowing, acid taste in mouth: Esophageal  4 Chest pain Analysis of chest pain Time 5-15 min: stable angina 15+ min: MI Chest pain lasting seconds or constant over weeks is not likely to be due to ischemia  4 Chest pain Analysis of chest pain Excerbating factors Alleviating factors Activity: Ischemic heart disease Rest/ Cessation of Activity: Ischemic Food: Esophageal NTG: (Cardiac or esophageal) lying back: Pericarditis Sitting up: Pericarditis Swallowing: Esophageal disease Antacids: Usually GI system Movement: Chest wall pain Respiration: PE, PTX, Pneumonia, pleurisy  4 Chest pain Analysis of chest pain Severity Pain score 0-10 variable from patient to patient 10:aortic dissection  16 History taking Important questions to ask: Hypertension, DM, high cholesterol, Family history: Ischemia Long plane trips, car rides, recent surgery or immobility, hypercoagulable state: PE Uncontrolled HTN/ Marfan’s: Aortic Dissection Rheumatic Diseases: Pleurisy Smoking: PTX, COPD, Ischemia  16 Physical examination vital signs : Fever: Pericarditis, Pneumonia Different BP in both arms: Aortic Dissection Decreased O2 Saturation: More commonly in pneumonia, PE, COPD Unexplained sinus tachycardia: PE  16 Physical examination Neck Tracheal Deviation: PTX JVD: Tension PTX, Tamponade, (CHF) Chest wall lesions: Herpes Zoster localized tenderness: musculoskeletal Lung Decreased breath sounds/hyperresonance: PTX Lung consolidation: Pneumonia Wheezing/prolonged expiration: Cardiac Asthma  16 Physical examination CV S3 gallop: HF S4 gallop: Ischemia Pericardial friction rub: pericarditis Muffled heart sounds: Tamponade Assess distal pulses NEURO Chest pain + neurologic findings: Aortic dissection  16 Investigations ECHO Evaluation of : ACS AORTIC DISSECTION (Ascending) Pulmonary embolism tamponade  16 Investigations ECG ST segment elevated (early sign MI) new-onset left bundle branch block (MI) new T-wave inversion (delayed sign of MI) wide Q waves (cardiac death)  4 Management Immediate assessment Assess airway, breathing, and circulation (ABCs). Initial Diagnostics ECG: Obtain within 10 minutes. Cardiac Biomarkers: Troponin levels Chest X-ray: To rule out pneumonia, pneumothorax, or aortic dissection. Further Evaluation Stress Testing: For non-acute cases, to evaluate for ischemia. Echocardiography: If structural heart disease is suspected.  4 Treatment 1. Acute Coronary Syndrome (ACS) Medications: Aspirin (chewable) for antiplatelet therapy Nitroglycerin (unless contraindicated) Anticoagulation Statins (unless contraindicated). Interventions: Coronary angiography and possible percutaneous coronary intervention (PCI) or thrombolytics.  4 Treatment 2.Pulmonary Embolism (PE) Medications: Anticoagulation (e.g., heparin). Interventions: Thrombolytic therapy if hemodynamically unstable. Supportive Care: Oxygen therapy if hypoxic.  4 Treatment 3.Pneumonia or Pleuritis Medications: Antibiotics (if bacterial pneumonia is suspected). NSAIDs or acetaminophen for pain control. Supportive Care: Oxygen if needed hydration  4 Treatment 4. Aortic Dissection Medications: Blood pressure control (e.g. beta-blockers) to reduce aortic stress. Pain management. Interventions: Surgical intervention may be necessary.  4 Treatment 5. Gastroesophageal Reflux Disease (GERD) Medications: Proton pump inhibitors (PPIs) or H2 blockers for acid reduction. Antacids for immediate relief. Lifestyle Modifications: Dietary changes Weight management  4 Treatment 6. Musculoskeletal Pain Medications: NSAIDs for pain relief Physical therapy if needed Supportive Care: Rest Ice application  4 Treatment 7. Anxiety or Panic Attack Medications: Benzodiazepines for acute anxiety relief SSRIs for long-term management Supportive Care: Reassurance Breathing techniques  4 Treatment Follow-Up and Monitoring Continuous monitoring for all patients with chest pain. Re-evaluation of treatment efficacy and adjustments based on patient response. Ensure appropriate follow-up appointments for chronic conditions or further evaluation.  7 MCQS Objective 1 Objective 2 Lorem ipsum dolor sit amet, Lorem ipsum dolor sit amet, consectetur adipiscing elit. consectetur adipiscing elit. Quisque non elit mauris. Cras Quisque non elit mauris. Cras euismod, metus ac finibus euismod, metus ac finibus finibus. finibus. Larana University | 2024  5 RESOURCES 1 2 3 THANK YOU Presented By :