Approach to Chest pain

Summary

This medical lecture focuses on the assessment of patients presenting with chest pain, emphasizing the importance of a thorough primary survey, including an EKG. It highlights the need to differentiate between life-threatening conditions such as acute myocardial infarction, aortic dissection, and pulmonary embolism, and less severe issues like GERD and musculoskeletal strain. Key questions for patient history are outlined, and physical exam findings that may indicate specific diagnoses are discussed. The lecture concludes with recommendations for further diagnostic tests, such as chest X-rays, lab work, and imaging studies.

Takeaways

• 🏥 Start with a primary survey for chest pain patients, including IV, O2, monitor, and ABCs.
• 🔬 Perform a focused history and physical (H&P), and obtain both a current and old EKG for comparison.
• 🤔 Ask about the quality, location, radiation, and factors that alleviate or worsen the chest pain.
• 🩺 Consider the 'six deadly' diagnoses: acute myocardial infarction, myocarditis, pericarditis, pericardial effusion, aortic dissection, pulmonary embolism, and pneumothorax.
• 📝 In the history, note symptoms like squeezing pain, tearing sensations, shortness of breath, and recent illness which can indicate different conditions.
• 🔍 Physical exam findings can guide diagnosis, such as diaphoresis for MI, unequal pulses for aortic dissection, and hypoxia for PE.
• 🩹 Past medical history and risk factors are crucial, including cardiac history, smoking, diabetes, and recent immobilization.
• 🧪 Labs like troponin, D-dimer, BNP, and blood gas can provide additional diagnostic information.
• 📈 Imaging studies like chest X-ray, CT, and echo may be necessary for further evaluation.
• ⚠ Always prioritize ruling out life-threatening conditions before considering less severe causes.

Q & A

What is the first step in assessing a patient with chest pain?

The first step in assessing a patient with chest pain is to perform a primary survey, which includes establishing IV access, administering oxygen, and monitoring with a pulse oximeter. Additionally, one should do the ABCs (Airway, Breathing, and Circulation) and conduct a focused history and physical exam.

Why is it important to get an EKG when a patient presents with chest pain?

An EKG is important because it can help diagnose conditions such as acute myocardial infarction, myocarditis, pericarditis, and pericardial effusion, which are part of the 'six deadly' differential diagnoses for chest pain.

What are the 'six deadly' conditions that should be ruled out in a patient with chest pain?

The 'six deadly' conditions include acute myocardial infarction, myocarditis, pericarditis, pericardial effusion, aortic dissection, pulmonary embolism, and pneumothorax.

How can the quality of chest pain help differentiate between different conditions?

The quality of chest pain can indicate different conditions. For instance, a squeezing or pressure-like pain that radiates to the jaw or arms and is worse with exertion may suggest a heart attack, while sharp, tearing pain radiating to the back and abdomen could indicate aortic dissection.

What specific questions should be asked during the history taking for a patient with chest pain?

During history taking, one should ask about the quality and location of the pain, whether it radiates, and what makes it better or worse. Specific questions include whether the pain is worse with deep breaths, changes in body position, exertion, or if it is provoked by pushing on the chest.

What are some non-deadly conditions that can cause chest pain?

Non-deadly conditions that can cause chest pain include gastroesophageal reflux disease (GERD), musculoskeletal strain, and esophageal rupture.

How can physical examination findings help in the diagnosis of chest pain?

Physical examination findings such as unequal pulses, unilateral weakness, hypotension, tachycardia, unequal breath sounds, and signs of heart failure can help direct the diagnosis towards conditions like aortic dissection, pneumothorax, myocarditis, pericarditis, or pulmonary embolism.

What additional tests might be helpful in the workup of a patient with chest pain?

Additional tests that might be helpful include a chest X-ray, blood tests such as troponin, D-dimer, BNP, blood gas analysis, and imaging studies like CT of the chest, angiography, or echocardiogram.

Why is it important to ask about past medical history and risk factors in a patient presenting with chest pain?

Past medical history and risk factors such as cardiac history, smoking, diabetes, hypertension, asthma, COPD, drug use, recent immobilization, leg swelling, history of clots, and cancer can provide important clues to the cause of chest pain and help prioritize the differential diagnosis.

What are some red flags during the physical examination that should raise suspicion for a serious condition in a patient with chest pain?

Red flags during the physical examination include diaphoresis, pale or cool skin, unequal pulses, unilateral weakness, hypotension, tachycardia, unequal breath sounds, muffled heart sounds, elevated JVD, and signs of peritoneal irritation.