Chest Pain Case Studies (PDF Format)

Chest PainStephen ChildDirector of Clinical TrainingGeneral and Respiratory PhysicianAuckland District Health Board

Which associated feature is most“reassuring”?a) Associated SOB with painb) Worse lying flatc) Radiation to rightshoulderd) Localised (

Would you do an ECG?a) Yesb) No0%0%ab

Would you do a CXR?a) Yesb) No0%0%ab

Which is the least useful exam finding ?a) Presence of heart murmurb) Abdominojugular reflexpositivec) Symmetrical air entry atapicesd) BP in both armse) Presence of S40% 0% 0% 0% 0%a b c d e

Would you do an acute referral to hospital ?a) Yesb) No0%0%ab

Chest PainDiagnosis (30%)Uncertain (70%)SeriousNot seriousT ension pneumoE mbolusP ericarditisI schemiaD issectionMSKHVSGI → 50% PPI responseShinglesPleurisyOther

Odds :• 6/400 or 1.5% had Unstable Angina or MIand 1.9 – 4.0% of patients discharged from EDhad acute coronary syndromeGP = “Best Guess”

Pre-testprobability+Tests=Post-testprobabilityNon-cardiacAtypicalCardiac pain+Risks+ECGTroponinCXR= Post-testprobability

“Low risk” - History• Sharp• Localised < 2 FB• Pleuritic or positional• Reproducible* Note * 48/51 Rt arm radiation = MI !

Pearls• Clinical exam (Hx + Dx) – 88% accuratefor non-organic• 13% suspected cardiac with histrionicactress vs 50%• NTG relief does not distinguish (35 vs41%)• 4 – 40% of ECG’s are “false negative”• 20% of CXR can be “useful”

Which of the following treatments improvessurvival in acute coronary symptoms?a) Aspirinb) Nitratesc) Diltiazemd) Oxygene) Morphinef) More than 1 above0% 0% 0% 0% 0% 0%a b c d e f

HospitalChest Pain - ?ACSAspirinClexane?Clopidogrel?IIb/IIIa antagMagnesiumB-BlockerACE-IHistoryPhysicalECGTroponinMyoglobulinETTAngioStop PCI CABG

“Serious”O2, AspirinIV + MonitorNitrates (beware Viagra/AS)

“Not Serious”- Trial PPI- Open mind- Review

Further exam by specialist revealeda) ? Split first heart soundb) small patch of psoariasisc) desquamating rash on palmsPossible diagnosis ??