I HUMAN CASE WEEK #7 49 YEAR Old REASON FOR ENCOUNTER: INTERMITTENT SQUEEZING CHEST PAIN, Exams of Health sciences

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COMPREHENSIVE I HUMAN CASE WEEK #7 49-YEAR

OLD PATIENT REASON FOR ENCOUNTER:

INTERMITTENT SQUEEZING CHEST PAIN LATEST STUDY

CASE ACTUAL SCREENSHOTS NEW!!!!!

The following table summarizes your performance on each

section of the case, whether you completed that section or not.

Time spent: 1dy 13hr 58min 29sec

Status: Submitted

Case Section Status Your Score Time spent Performance Details History Done 63% 12hr 5mi n 12sec (^60) questions asked, 22 to the case's list correct, 13 missed relative Physical exams Done 83% (^) 13hr 52min 55sec 53 exams performed, partially correct, case's list

0

19 correct, missed relative

to the Key findings organization Done 34min 40sec 14 findings listed; 16 listed by the case Problem statement Done 1hr 9mi n 29sec 150 words long; the case's was 117 words Differentials Done 88% 13min 14sec (^13) items missed in relative the to DDx, 7 the case's list correct, 1 Differentials ranking Done 88% (lead/alt score) 88% (must not miss score) 7min 38sec Tests Done 89% 50min 23sec (^10) tests relative ordered, to

the correct, 1 case's list missed Diagnosis Done 100% 21sec Management plan Done 46min 0sec 1645 words long; the case's was 79 words Exercises Done 68% (of scored items only) 32min 51sec 3 of 5 correct 1 partially correct (of scored items only)

AA

History Notecard by AA on case

Use this worksheet to organize your thoughts before developing a differential diagnosis list.

1. Indicate key symptoms ( Sx ) you have identified from the history. Start with the patient's reason(s) for the encounter and add additional symptoms obtained from further questioning.
2. Characterize the attributes of each symptom using details in the appropriate column and row. "OLDCARTS". Capture the
3. Review your findings and consider possible diagnoses that may correlate with these symptoms.(Remember to consider the patient's age and risk factors.) Use your ideas to help guide your physical examination the case. in the next section of HPI Sx = chest pain Sx = Sx = Sx = Sx = Sx = Onset 2.5 hours ago Location deep in chest, pierces through back Duration Characteristics worsens with deep inspiration Aggravating worsens when laying down, moving, and breathing Relieving eased pain when leaning forward Timing / Treatments Severity 8/

History of Present Illness

Category Data entered by AA

Reason for Encounter Chest pain History of present illness A 57 - year-old female 10 days status post inferolateral STEMI with stent placement, presents to the ED with a 2.5-hour history of progressively worsening chest pain. The pain is sharp and stabbing, gets to pierce through her back with inspiration. Pain is partially relieved by sitting up and leaning forward. She reports mild nausea without vomiting, denies fever/chills, palpitations, lightheadedness/syncope, SOB, cough, URI, or extremity/catheterization site pain or swelling. She reports compliance with her antiplatelet medications (ASA and clopidogrel), pantoprazole, and aspirin since discharge. On exam, patient is febrile, shallow respirations at normal rate, low-normal oxygen saturation, and has pericardial friction rub. PMH is significant for hypertension, hyperlipidemia, tobacco abuse, obesity, and type- 2 diabetes. family history of heart attack and

Past Medical History

Category Data entered by AA

Past Medical History Hypertension Hyperlipidemia Hospitalizations / Surgeries Acute inferolateral wall ST-elevation myocardial infarction with PCI/stenting of the right coronary artery (RCA). Balloon angioplasty of the left circumflex artery.

Medications

Category Data entered by AA

Medications Clopidogrel 75 mg QD Atorvastatin 80 mg QD at bedtime

Pantoprazole 40 mg QD Aspirin 81 mg QD

Allergies

Category Data entered by AA

Allergies Bactrim (rash)

Preventive Health

Category Data entered by AA

Preventive health Up to date immunization including flu shots annually. Reports gynecology normal. exam was

Family History

Category Data entered by AA

Family History Father - Heart attack, 59 years old Mother - Type 2 Diabetes Sister - Type 2 Diabetes

Social History

Category Data entered by AA

Social History Freelance worker, telephone sales. Smoked a pack and a half for the past 25 years. Quitted since she’d the heart attack and takes a healthy heart diet.

Review of Systems

Category Data entered by AA

General Slightly fatigued. Laying still to avoid movement, breathing slowly. Integumentary / Breast Warm skin; no significant diaphoresis. HEENT / Neck Denies any problems with headaches, double vision, difficulty with night vision, hearingproblems, ear pain, sinus problems, chronicsore throats,or difficulty swallowing. Cardiovascular Chest pain. Heart attack 10 days ago. Denies history of irregular heartbeats nor Hypertension Hyperlipidemia palpitations.

Respiratory Denies wheezing and sputumproduction. Gastrointestinal Reports mild nausea and reflux. Genitourinary Denies urinary frequency, pain, incontinence, or difficulty. Musculoskeletal Denies chest injury. No problems with muscles and joints. Allergic / Immunologic Endocrine Denies problems with heat or cold intolerance, increased thirst, increased sweating, frequent urination, or change in appetite. Hematologic / Lymphatic No reports of bruising, bleeding gums, sites of increased bleeding. nose bleeds, or other Neurologic Denies dizziness, seizures, numbness, or weakness. Psychiatric Reports nervousness due to chest pain.

Physical Exams

Category

Data entered by AA

General Obese with a BMI of 29.4. AOx Skin (^) is dry and febrile. Skin Skin warm and dry with no lesions. Nails without ridging, pitting, or peeling. Capillary refill < 2 sec. Quincke’s Test: Blanching observed.

HEENT / Neck Head: Normocephalic, atraumatic, no deformities, facial features symmetric.Temporal arteries non-tender to palpation. Frontal and maxillary sinuses non-tender. Eyes: Normal conjunctivae on inspection. Visual acuity with Snellen pocket card: OD 20/20, OS 20/20. Throat/Neck: Mucous membranes moist. Oropharynx without erythema, edema, or exudate. No stridor, no foreign body. No visible scars, deformities, or other lesions on neck inspection. Trachea is midline and freely WNL mobile. JVP Cardiovascular PMI nondisplaced. JVP WNL. No significant change while standing, squatting, sustained handgrip. during Valsalva maneuver or with Chest / Respiratory Thorax atraumatic; no postsurgical scars. Respirations shallow, normal rate, nonlabored. No visible bounding of the chest. No tenderness to chest wall or vertebral body palpation. No palpable thrill. Normal tactile fremitus. Thorax normal/symmetrical to percussion. Normal lungs sounds bilaterally. Abdomen Abdomen atraumatic, obese, nondistended. Normoactive bowel sounds. No hepatosplenomegaly or palpable masses. nontender throughout exam. Soft, Genitourinary / Rectal Normal pelvic exam. No masses or tenderness. genitalia. Normal external Musculoskeletal / Osteopathic Structural Examination Normal No muscle bulk. No evidence of swelling. calf tenderness or inflammatory peripheral edema. (^) signs. No No asymmetry or deformity of the back. No tenderness or spasm of the paraspinal muscles. No localized tenderness of the pelvic structures. spinous processes or Neurologic PERRLA.CN II-XII intact. Psychiatric AOx Lymphatic No pathologically enlarged lymph nodes in the cervical, supraclavicular, axillary or inguinal chains.

*History of present illness

Patient known to be ischemic heart. Recently he developed retrosternal burning and compressing chest pain, with acute onset intermittent course for 5 hours. Not radiating , not relieved by sublingual nitrates , not associated with dyspnea. there is no history of syncope, palpitation, bluish discoloration of peripheries or lower limb oedema.

The pain is not aggravated by chest movement and not relieved by changing posture.

There is no cough, haemoptysis, or audible breathing sounds. There is no history of dysphagia, odynophagia, hematemesis or heartburn. There is no history of chest trauma. There were no symptoms suggesting other systems affection. *Past History Patient has history of PCI since 2 years. The patient condition started 3 years ago when he had similar attacks of chest pain that occurred repeatedly despite receiving sublingual Nitro glycerine tablets. There are no other chronic diseases, no drug allergy, no history of operations and no blood transfusion *Family History There are no chronic disease running in family or similar attacks. Emergency Department Examination 1ry Survey: Airway: The patient has patent airways Breathing: By Inspection, the Respiratory Rate is 14 breathes / minute, there is symmetrical chest movements and there is no chest deformity. By Palpation, There is no chest tenderness, there is symmetrical chest expansion & there is no shifting of trachea. By Percussion, No Hyper-resonance By Auscultation, No Abnormal Breathing sounds. Circulation: Central Pulsation is felt, central to peripheral pulsation is comparable & peripheraltoperipheral pulsation is also comparable. Radial pulsation is 63 beats per min, regular, of average volume, symmetrical in both sides and has no special characters. Blood Pressure: 115 / 85 mmHg (Normal) Capillary Filling time: less than 2 seconds. Disability: The Patient is Alert on AVPU Score.

The pupils are rounded, central, responsive to light & equal on both sides. Exposure: No apparent injuries in body. General Examination Patient is alert , conscious , oriented to time , place and persons , average built , quiet facial expression , no special decubitus , average intelligence ,he's cooperative Cardiac Examination By inspection: There is no skin redness, pigmentation, ulceration, fistulae or scars. Respiration is abdomenothoracic. No visible pulsation at the apex of the heart. By Palpation: Palpable pulsation of the heart at the fifth intercostal space in the midclavicular line. There are no masses, swellings, tenderness or pulsating masses. By Auscultation: No abnormal cardiac sounds, muffling or murmurs were heard at the apex of the heart, xiphisternal area and aortic areas. Differential Diagnosis

1. Acute Coronary Syndrome (most probable)
2. Pericarditis excluded by absence of localized friction rub over pericardium.
3. Aortic Dissection excluded by absence of unequal pulsation or pulsating masses.
4. Musculoskeletal Pain excluded by not being aggravated by chest movement and not being relieved by changing posture.
5. Pleurisy, Bronchitis, Broncho-Pneumonia or Lung Carcinoma excluded by absence of cough, haemoptysis, friction rub on the chest and audible abnormal breathing sounds.
6. Esophagitis or peptic ulcer excluded by absence of history of dysphagia, odynophagia, hematemesis or heartburn.

Provisional Diagnosis

A 58 years old male ischemic patient came complaining of intermittent retrosternal sever chest

tightness, with no radiation for 5 hours duration most probably caused by UnStable Angina

Pectoris not complicated.

Management

The patient should be admitted and have the following investigations:

1. 12 Leads ECG for any abnormal findings including T-wave inversion or ST segment elevation.

2. Cardiac enzymes (Myoglobin, Troponin I and CK MB.)

3. Chest X ray (for exclusion of trauma, pulmonary conditions & aortic aneurysm).

The patient should receive:

1. Aspirin 300 mg for chewing (to prevent propagation of the thrombus)

2. Oxygen inhalation session (5-10 Litres / minute)

3. Nitro glycerine 10 mg sublingual tablets (for coronary vasodilatation) >> ask 1st^ about intake of

sildenafil.

4. Morphine 5-10 mg IV (for relieving pain)

If the patient’s condition improved he should be put under observation for 24 hours.

Drugs taken after stabilization of the condition:

5. Heparin SC injection (to prevent new thrombus formation)

6. Glycoprotein IIb & IIIa inhibitors.

7. Beta Blockers to decrease cardiac demands

8. Diltiazim (if beta blockers are contraindicated, e.g. Asthma) If the patient’s condition didn’t improve or

MI was present

9. Primary PCI within 90 minutes (if available)

10. Thrombolytics if PCI is not available (unless absolutely Contraindicated)

Scientific background

Chest pain

INTRODUCTION

Patients with acute no traumatic chest pain are among the most challenging patients cared for by emergency physicians.

They may appear seriously ill or completely well and yet remain at significant risk for sudden death or an acute

myocardial infarction (AMI).

CLINICAL FEATURES

The typical pain of myocardial ischemia has been described as retrosternal or epigastric squeezing, tightening, crushing,

or pressure-like discomfort. The pain may radiate to the left shoulder, jaw, arm, or hand. In many cases, particularly in

the elderly, the predominant complaint is not of pain, but of a poorly described visceral sensation with associated

dyspnea, diaphoresis, nausea, lightheadedness, or profound weakness. The onset of symptoms may be sudden or

gradual, and

Symptoms usually last minutes to hours. In general, symptoms that last less than 2 minutes or are constant over days are

less likely to be ischemic in origin. Symptoms that are new or familiar to the patient but now occur with increasing

frequency, severity, or at rest are called unstable and warrant urgent evaluation even if they are absent at the time of

presentation. Cardiac risk factors should be used only to predict coronary artery disease within a given population and

not in an individual patient. It should also be mentioned that women, diabetics, and patients with psychiatric disorders

may have more subtle signs of ischemia.

PHYSICAL EXAMINATION

Patients with acute myocardial ischemia may appear clinically well or be profoundly hemodynamically unstable. The

degree of hemodynamic instability is dependent on the amount of myocardium at risk, associated dysrhythmias, or

preexisting valvular or myocardial dysfunction.

Worrisome signs may be clinically subtle, particularly the presence of sinus tachycardia, which may be due to pain and

fear or may be an early sign of physiologic compensation for left ventricular failure. Patients with acute ischemia often

have a paucity of significant physical findings. Rales, a third or fourth heart sound, cardiac murmurs, or rub are clinically

relevant and important findings.

The presence of chest wall tenderness has been demonstrated in 5 to 10 percent of patients with AMI, so its presence

should not be used to exclude the possibility of acute myocardial ischemia.

Also, response to a particular treatment such as nitroglycerin should not be taken as evidence of a certain disease.

DIAGNOSIS AND DIFFERENTIAL Electrocardiography

Of all the diagnostic tools clinically used in assessing chest pain, the electrocardiogram (ECG) is the most

reliable when used and interpreted correctly. Patients with acute infarctions may have ECG findings that range

from acute ST-segment elevations to completely normal. This range means that the ECG is useful only when it

has a positive, or diagnostic, finding. New ST-segment elevations, Q waves, bundle branch block,

and T-wave inversions or normalizations are strongly suggestive of ischemia and warrant

aggressive management in the emergency department (ED). The presence of a normal or

unchanged ECG does not rule out the diagnosis of acute myocardial ischemia.

Serum Markers

Serum markers, if positive, are highly specific for AMI. Myoglobin rises predictably in AMI but is

found in all muscle tissue, making it less reliable in the setting of AMI. Creatinine kinase and its

MB isoenzyme constitute the historical gold standard for diagnosing AMI. Cardiac-specific

troponin I is not found in skeletal muscle, so it has a much greater sensitivity and specificity for

AMI. The documentation of normal serum markers in the bloodstream does not exclude the

diagnosis of AMI.

In addition, these enzymes will not become elevated in serious disease conditions such as

unstable angina. The use of these markers can aid the clinician in assessing risk for patients

with chest pain, including disposition within the hospital. It must be remembered that a serial

enzyme evaluation is needed to appropriately risk stratify individual patients.

Echocardiography

Emergency 2-dimensional echocardiography may have value in the evaluation of chest pain

when the ECG is nondiagnostic, eg, in patients with pacemakers, have a bundle branch block, or

have a baseline abnormal ECG. The finding of regional wall motion abnormalities in the acutely

symptomatic patient is strongly suggestive of active ischemia. Wall motion abnormality also

may represent previous myocardial injury. Twodimensional echocardiography also may aid in

the diagnosis of other conditions that may mimic ischemic disease, such as pericarditis, aortic

dissection, or hypertrophic cardiomyopathy.

Provocative Tests

Many tests currently being performed in some EDs will unmask otherwise unrecognized,

clinically significant ischemic disease. Patients with atypical chest pain and a normal stress

thallium or technetium scan have a very low incidence of short- and long-term subsequent

ischemic events.

Thallium or sestamibi testing can be done in the ED to further risk stratify patients in the

hospital and perhaps be used in consideration for patient discharge from the ED.

Differential Diagnosis

The priority must always be to exclude life-threatening conditions, and the ED physicians should

organize their test-ordering strategies to screen for those conditions first. (Table lists possible

causes of nontraumatic chest pain.)

Table Serious Causes of Chest Pain and Their Presentation

Diagnosis Presentation

Pulmonary embolism Sudden onset, pleuritic pain, and dyspnea

Aortic dissection Tearing pain with radiation to back, neurologic symptoms

Pericarditis Positional ache, dyspnea

Pneumothorax Pleuritic pain and dyspnea

Acute coronary syndrome Vague, pressure-like pain, radiation to arm, neck, jaw

Esophageal rupture Constant retrosternal, epigastric pain, history of inciting event

Pneumonia Pleuritic pain, cough, dyspnea, chills

SPECIFIC CAUSES OF CHEST PAIN Angina Pectoris

The pain of chronic stable angina is episodic and lasts 5 to 15 minutes. It is precipitated by exertion and

relieved with rest or sublingual nitroglycerin within 3 minutes. The pain is typically visceral in nature

(aching, pressure, and squeezing), with radiation to the neck, jaw, arm, or hand. In individual patients

the character of each attack varies little with recurrent episodes. Most patients can differentiate their

usual angina from other causes of pain. Physicians evaluating patients with stable angina should screen

carefully for changes in the pattern that would suggest a shift from stable to unstable angina or even

suggest a different diagnosis.

Unstable Angina :

Patients who complain of recent onset of angina, changes in the character of the angina, or angina at

rest are thought to have an unstable pattern of their angina. They are at risk for an AMI or sudden

cardiac death (see Chapter 21 for management).

Variant (Prinzmetal) Angina

This form of angina is thought to be due to spasm of the epicardial vessels in patients with normal coronary

arteries (one third of cases) or in patients with underlying atherosclerotic disease (two thirds of cases). Pain

typically occurs at rest and may be precipitated by the use of tobacco or cocaine. The ECG typically shows

STsegment elevations during an acute attack. Acute Myocardial Infarction

Ischemic pain that lasts longer than 15 minutes, is not relieved by nitroglycerin, or is accompanied by diaphoresis,

dyspnea, nausea, or vomiting suggests the diagnosis of AMI. The clinician must understand the limitations of the

screening tools used in the ED and should have a high level of suspicion for AMI in patients with risk factors and

prolonged or persistent symptoms for whom there is no other clear diagnosis. Aortic Dissection

This diagnosis should be suspected in the patient who complains of sudden onset of severe, tearing pain in the

retrosternal or midscapular area. High-risk patients are also those at risk for AMI, specifically the middle-age

hypertensive male. The patient may be hypertensive or hypotensive in shock. There may be a diastolic murmur of

aortic regurgitation, indicating a proximal dissection, or distal pulse deficits, indicating a distal dissection. The

dissection may occlude coronary ostia, resulting in myocardial infarction, or the carotids, resulting in cerebral

ischemia and stroke. Chest x-ray, computed tomography, trans esophageal echocardiography (TEE), and

angiography can aid in the diagnosis of this condition. Musculoskeletal Causes

Chest pain due to irritation or inflammation of structures in the chest wall is commonly seen in the ED. Possible

causes include costochondritis, intercostal strain due to severe coughing, and pectoralis muscle strain in the setting

of recent physical exertion. Patients will complain of sharp pain that is worsened with movement of the chest wall

(eg, coughing, and some pain that can be elicited by palpation of the chest wall). These findings in patients without

any other symptoms and no history of significant cardiac disease support the diagnosis of musculoskeletal pain.

This pain is generally responsive to no steroidal anti-inflammatory drugs. It is important to emphasize that the

presence of chest wall tenderness does not rule out the possibility of myocardial ischemia.

Gastrointestinal Causes

Esophageal reflux, dyspepsia syndromes, and esophageal motility disorders can produce chest pain that is difficult

to distinguish from ischemic pain. Patients may complain of burning, gnawing pain associated with an acid taste

radiating into the throat. Pain may be exacerbated by meals, worsen when supine, and may be associated with

belching. Clinicians should determine whether the symptoms are due to a GI disorder based on the clinical

presentation and the absence of findings and/or risk factors suggesting an ischemic cause. Diagnostic decisions

should not be made on the basis of a response to a therapeutic trial of antacids, GI cocktails, or nitroglycerin.

EMERGENCY DEPARTMENT CARE AND DISPOSITION

Assume that every patient complaining of chest pain might be having an AMI.

Patients with suspicious histories should have large-bore IV line established, a cardiac monitor,

supplemental O 2 , and ECG obtained as soon as possible. Vital signs and pulse oximetry should be

monitored continuously.

Ask patients about cardiac risk factors, preexisting coronary artery disease, quality of chest pain, time

of onset and duration of symptoms, and whether the pattern has been stable, unstable, continuous, or

intermittent. Ask specifically for clues to noncardiac causes of chest pain: ability to elicit pain by

movement or cough; the relation of pain to meals; or pain that is of sudden onset, referred to the back,

or pleuritic in nature.

Examine patients while noting evidence of heart failure or valvular insufficiency, pericardial rubs, or

tenderness of the chest wall. Specifically, physicians should ask whether pain elicited on palpation of

the chest wall exactly reproduces the patient's pain.

An ECG should be obtained on all patients for whom there is a reasonable suspicion of myocardial

ischemia. A normal ECG, although minimizing the likelihood of an AMI, does not definitively rule out the

possibility of MI.

If the etiology of chest pain remains unclear in some patients, clinicians should consider more diagnostic

tests as guided by clinical suspicion and findings.

Clinicians should not use patients' clinical response to GI cocktails, nitroglycerin, or NSAIDs to exclude

the possibility of myocardial ischemia.

In patients with nondiagnostic ECGs for whom there is a clinical suspicion for ischemia, clinicians should

consider provocative testing, echocardiography, or admission and observation. Physicians should not

rely on serum enzyme testing to rule out the possibility of clinically significant disease.