Professional Documents
Culture Documents
CHEST DISCOMFORT
Elija Sunga, MD Manila Med
42
31 28
Pericarditis
Pleuritis/Pneumonia Pulmonary Embolism
4
2 2
Lung CA
Aortic Aneurysm Aortic Stenosis
1.5
1 1
Herpes Zoster
Condition Duration
Stable Angina More than 2 and less than 10 min
Quality
Pressure, tightness, squeezing, heaviness, burning
Location
Retrosternal, often with radiation to or isolated discomfort in neck, jaw, shoulders, or arms frequently on left
Features
Precipitated by exertion, exposure to cold, psychologic stress
Condition Duration
Unstable Angina 10-20 min
Quality
Location
Features
Similar to angina, but occurs with low levels of exertion or even at rest
Condition Duration
Acute MI Variable; often more than 30 min
Quality
Location
Features
Unrelieved by nitroglycerin May be associated with evidence of heart failure or arrhythmia
Condition Duration
Aortic Stenosis Recurrent episodes as described for angina
Quality
As described for angina
Location
Features
Condition Duration
Quality
Location
Retrosternal or toward cardiac apex; may radiate to left shoulder
Features
May be relieved by sitting up and leaning forward
Condition Duration
Aortic Dissection Abrupt onset of unrelentin g pain
Quality
Tearing or ripping sensation; knifelike
Location
Anterior chest, often radiating to back, between shoulder blades
Features
Associated with HPN and/or underlying connective tissue disorder pericardial rub, pericardial tamponade, or loss of peripheral pulses
Condition Duration
Quality
Location
Often lateral, on the side of the embolism
Features
Dyspnea, tachypnea, tachycardia, and hypotension
Condition Duration
Pulmonary Variable HPN
Quality
Pressure
Location
Substernal
Features
Dyspnea, signs of increased venous pressure including edema and jugular venous distention
Condition Duration
Spontaneo us Pneumoth orax Sudden onset; several hours
Quality
Pleuritic
Location
Lateral to side of pneumothor ax
Features
Dyspnea, decreased breath sounds on side of pneumothor ax
Condition Duration
Pneumonia Variable
Quality
Pleuritic
Location
Unilateral, often localized
Features
Dyspnea, cough, fever, rales, occasional rub
Condition Duration
Reflux
Quality
Location
Substernal, epigastric
Features
Worsened by postprandial recumbency Relieved by antacids
Condition Duration
Esophageal spasm 230 min
Quality
Pressure, tightness, burning
Location
Features
Condition Duration
PUD Prolonged
Quality
Burning
Location
Epigastric, substernal
Features
Relieved with food or antacids
Condition Duration
Gallbladder Disease Prolonged
Quality
Burning, pressure
Location
Epigastric, right upper quadrant, substernal
Features
May follow meal
Condition Duration
Musculoskeletal Disease Variable
Quality
Aching
Location
Variable
Features
Aggravated by movement May be reproduced by localized pressure on examination
Condition Duration
Herpes Zoster Variable
Quality
Sharp or burning
Location
Features
Condition Duration
Emotional Variable; and may be psychiatric fleeting conditions
Quality
Variable
Location
Variable; may be retrosternal
Features
Situational factors may precipitate symptoms Anxiety or depression often detectable with careful history
Physical Exam
BP of both arms pulses in both legs pericardial rubs systolic and diastolic murmurs third or fourth heart sounds pressure on the chest wall may reproduce symptoms in patients with musculoskeletal cause
Diagnostics
presence of ECG changes consistent with ischemia or infarction is associated with high risks of acute MI risk of life-threatening complications is low for patients with normal or only NSSTWC if these patients are not considered appropriate for immediate discharge, they are often candidates for early exercise testing
4%
51%
2%
14%
Diagnostics
Cardiac Markers - Troponins I and T have superceded creatine kinase and CK-MB as the markers of choice for detecting myocardial injury - Single values of these markers do not have high sensitivity for acute MI or for prediction of complications
Diagnostics
Clinicians frequently employ therapeutic trials with SL nitroglycerin, antacids or PPI A common error is to assume that a response to any of these interventions clarifies the diagnosis patient's response may be due to the placebo effect
Guidelines advocate:
ECG for all patients with chest pain who do not have an obvious noncardiac cause of their pain CXR for patients with signs or symptoms consistent with CHF, VHD, pericardial disease, aortic dissection or aneurysm
Guidelines emphasize:
Rapid identification and treatment of patients for whom emergent reperfusion therapy, either via PCI or thrombolytic agents, is likely to lead to improved outcomes
Guidelines emphasize:
patients with low risk for complications can be observed in non-coronary care unit settings, undergo early exercise testing, or be discharged home minimum length of stay in a monitored bed for a patient who has no further symptoms: 12h or less if exercise testing is available
PALPITATIONS
Palpitations:
"thumping," "pounding," or "fluttering" sensation in the chest can be either intermittent or sustained and either regular or irregular unusual awareness of the heartbeat often noted when the patient is quietly resting, during which time other stimuli are minimal
Palpitations:
palpitations that are positional generally reflect a structural process within (atrial myxoma) or adjacent to (mediastinal mass) the heart
Palpitations:
cardiac (43%) psychiatric (31%) miscellaneous (10%) unknown cause (16%)
Palpitations: Cardiac
intermittent: PAC, PVC regular, sustained: SVT, VTach irregular, sustained: AF most arrhythmias are not associated with palpitations ask the patient to "tap out" the rhythm of the palpitations or to take his pulse while experiencing palpitations
Palpitations: Cardiac
hyperdynamic states caused by catecholamine stimulation from exercise, stress, or pheochromocytoma can lead to palpitations common among athletes, especially older endurance athletes
Palpitations: Cardiac
AR: enlarged ventricle and accompanying hyperdynamic precordium lead to palpitations factors that enhance the strength of myocardial contraction: tobacco, caffeine, aminophylline, atropine, thyroxine, cocaine, amphetamines
Palpitations: Psychiatric
panic attacks anxiety states somatization Patients with psychiatric causes for palpitations more commonly report a longer duration (>15 min) and other accompanying symptoms than do patients with other causes
Palpitations: Miscellaneous
thyrotoxicosis drugs ethanol spontaneous skeletal muscle contractions of the chest wall pheochromocytoma systemic mastocytosis
Approach to Palpitations
principal goal: determine if caused by a life-threatening arrhythmia patients with preexisting CAD or risk factors for CAD are at greatest risk for ventricular arrhythmias as a cause for palpitations
Approach to Palpitations
ECG: to document arrhythmia If exertion is known to induce arrhythmia and palpitations, exercise ECG can be used If arrhythmia is infrequent: Holter monitoring, telephonic monitoring, implantable loop recorder
Approach to Palpitations
Most patients with palpitations do not have serious arrhythmias or underlying structural heart disease Occasional benign PAC or PVC can often be managed with beta-blocker if sufficiently troubling to the patient Abstinence from alcohol, tobacco, or illicit drugs
Approach to Palpitations
psychiatric causes may benefit from cognitive or pharmacotherapies palpitations are at the very least bothersome and could be frightening to the patient Once serious causes for the symptom have been excluded, the patient should be reassured that the palpitations will not adversely affect prognosis
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