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Approach to a patient with Chest Pain presenting in primary care setting Saqer Abbadi BAU

Approach to a patient with Chest Pain presenting in primary care setting Saqer Abbadi BAU.

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Approach to a patient with Chest Pain presenting in primary care setting Saqer Abbadi BAU

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  1. Approach to a patient with Chest Pain presenting in primary care settingSaqerAbbadiBAU

  2. -Chest pain one of the most common causes of ER visits in Jordan(Ranging from trivial causes to a life-threatning ones)-The most common cause of chest pain?-More than one third of MI patients die before they arrive to the hospital

  3. There is no fail-proof algorithm for approaching chest pain. In general, have agreater index of suspicion for ischemic causes in the elderly, diabetic populations,and those with a history of CAD

  4. Causes:- Cardiogenic- Non-cardiogenic

  5. 1. Heart, pericardium, vascular causesa. Stable angina, unstable angina, b. MIc. Pericarditis(pleuritic CP)d. Aortic dissection(Tearing, interscapular)5 Risk factors in Hx-

  6. If pain changes with respiration(pleuritic), changes withbody position or if there istenderness of chest wall,cardiac cause of pain ishighly unlikely.

  7. If you suspect a cardiaccause of the pain, sublingualnitroglycerin is appropriate.Also give aspirin if thepatient does not have ableeding disorder. If nitroglycerin relieves thepain, a cardiac cause ismore likely.

  8. A common presentation is apatient with chronic stableangina who presents withsymptoms suggestive ofUSA. The following are theinitial steps:• Obtain ECG and cardiacenzymes• Give aspirin• Begin IV heparin

  9. 2. Pulmonary: Pulmonary embolism (can have pain with pulmonary infarction, Hemoptysis MC sign on ECG?),pneumothorax, pleuritis (pleural pain), pneumonia, status asthmaticus

  10. 3. GI: Gastroesophageal reflux disease (GERD), diffuse esophageal spasm, pepticulcer disease, esophageal rupture45 y/o m sever rt. Cp with rash?

  11. 4. Chest wall: Costochondritis, muscle strain, rib fracture, herpes zoster, thoracicoutlet syndrome23 y/o heal m co/ sevcp sob swepxtacctacpsmwhi part?

  12. 5. Psychiatric: Panic attacks, anxiety, somatization6. Cocaine use can cause angina or MI.

  13. Approach to a Patient with CPFirst of all, RESUCITATE (Abc..)Hx:a. Character of the pain (pressure, squeezing, tearing, sharp, stabbing, etc.)b. Location of painc. Severity of pain

  14. d. Duration of paine. Setting in which pain occurred (during exertion, at rest, after meal)f. Radiation of paing. Aggravating or alleviating factors (e.g., meal, exertion, rest, respiration)h. Does the patient have a cardiac history? Ask about results of previous stress tests,echocardiograms, cardiac catheterization, or of any procedures (PCI or CABG).i. If the patient has a history of angina, ask how this episode differs from previousones (more severe? longer duration?).

  15. Physical Examination:Perform a focused physical examination, with attention to cardiopulmonary,abdominal, and musculoskeletal examination.

  16. Tests:a. Obtain ECG in almost all cases(20% missed in 1st hour)b. Cardiac enzymes (CK, CK-MB, troponin) depending on clinical suspicion(Appear after 3 hours)c. Obtain chest radiograph (CXR) in almost all casesd. Under appropriate clinical setting, work up the patient for pulmonary embolism(PE)

  17. It can be difficult to distinguish between GI causes of chest pain and angina.The decision of whether to initiate a cardiac workup is dependent on a patient’soverall risk of CAD and the clinical presentation.

  18. To summarize:Patient with Chest Pain…1- As always, check vital signs. In most cases, obtain a 12-lead ECG. Compare withan old ECG. Get more information about the patient’s cardiac history and currenthistory of chest pain.

  19. 2. Order cardiac enzymes (creatine kinase; creatine kinase-myocardial bound; troponin)× 3, every 8 hours, if unstable angina or MI is suspected.

  20. 3. Consider CXR (pneumothorax, widened mediastinum, pleural effusion). ConsiderABG or CT scan/V/Qscan if PE is suspected.

  21. 4. If myocardial ischemia is suspected:a. Oxygen, 2 L by NC, titrate up as neededb. Nitroglycerin (sublingual) for pain; if pain continues, can give morphine IVc. Keep systolic BP > 90 mm Hg.d. Aspirin

  22. e. Heparin—give a loading dose, then start a drip. Check the PTT in 6 hours.Perform a guaiac stool test before starting heparin.f. Put the patient on a cardiac monitor, and consider transfer to a cardiac careunit.

  23. THANK YOU

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