Theme: Chest pain
A. Myocardial infarction
B. Gastro-oesophageal reflux disease
C. Anxiety
D. Pleurisy
E. Pneumothorax
F. Pericarditis
G. Myocarditis
H. Pneumonia
I. Pulmonary embolism
J. Shingles
For each one of the following scenarios select the most likely diagnosis:
- A 42-year-old overweight man presents with a two day history of anterior chest pain that is worse on deep inspiration and lying down
- A 67-year-old female with a history of chronic lymphocytic leukaemia presents with a 3 day history of burning pain in the right lower chest wall. Clinical examination is unremarkable
- A 25-year-old man with a history of Marfan’s disease presents with sudden onset shortness of breath and pleuritic chest pain
6- Pericarditis
7- Shingles: Pain and paraesthesia often precede the classic vesicular rash seen in shingles.
8- Pneumothorax: more common in patients with Marfan’s disease.
Characteristic exam features of MI
Cardiac-sounding pain:
- heavy, central chest pain they may radiate to the neck and left arm
- nausea, sweating
- The presenting features may be atypical in the elderly and those with diabetes (and woman)
- elderly patients and diabetics may experience no pain
- Clamminess
Risk factors for cardiovascular disease
Characteristic exam features of pneumothorax
- History of asthma, Marfan’s etc
- Sudden dyspnoea and pleuritic chest pain
Characteristic exam features of PE
- Sudden dyspnoea and pleuritic chest pain
- Hemoptysis, hypoxia, and small pleural effusions may be present
- Calf pain/swelling
- Current combined pill user
- malignancy
Characteristic exam features of Pericarditis
- Sharp pain relieved by sitting forwards
- May be pleuritic in nature
Characteristic exam features of Dissecting aortic aneurysm
- ‘Tearing’ chest pain radiating through to the back
- Unequal upper limb blood pressure
Characteristic exam features of Gastro-oesophageal reflux disease
- Burning retrosternal pain
- Other possible symptoms include regurgitation and dysphagia
Characteristic exam features of Musculoskeletal chest pain
One of the most common diagnoses made in the Emergency Department. The pain is often worse on movement or palpation.
May be precipitated by trauma or coughing
Does rash come first in Shingles or pain?
Pain often precedes the rash
Where do aortic dissection happen?
It most commonly occurs in the ascending aorta or just distal to the left subclavian artery (less common)
In which population is aortic dissection most common? What age?
It is most common in Afro-carribean males aged 50-70 years.
How are aortic dissections classified and how are each managed?
- In the Stanford classification system the disease is classified into lesions with a proximal origin (Type A) and those that commence distal to the left subclavian (Type B).
- Proximal (Type A) lesions are usually treated surgically, type B lesions are usually managed non operatively.
Imaging for aortic didssection
- Diagnosis may be suggested by a chest x-ray showing a widened mediastinum
- Confirmation of the diagnosis is usually made by use of CT angiography
Features of perforated peptic ulcer disease
- Patients usually develop sudden onset of epigastric abdominal pain, it may be soon followed by generalised abdominal pain.
- There may be features of antecendant abdominal discomfort
When is the pain of gastric ulcer usually worse?
typically worse immediately after eating
How is diagnosis made for perforated peptic ulcer?
Diagnosis may be made by erect chest x-ray which may show a small amount of free intra-abdominal air (very large amounts of air are more typically associated with colonic perforation)
Treatment of perforated peptic ulcer
Treatment is usually with a laparotomy, small defects may be excised and overlaid with an omental patch, larger defects are best managed with a partial gastrectomy.
What is Boerhaaves syndrome?
Spontaneous rupture of the oesophagus that occurs as a result of repeated episodes of vomiting.
Features of boerhaaves syndrome?
Patients usually give a history of sudden onset of severe chest pain that may complicate severe vomiting.
Severe sepsis occurs secondary to mediastinitis.
Imaging of boerhaaves syndrome
Diagnosis is CT contrast swallo
Treatment of Boerhaaves syndrome
- Treatment is with thoracotomy and lavage, if less than 12 hours after onset then primary repair is usually feasible, surgery delayed beyond 12 hours is best managed by insertion of a T tube to create a controlled fistula between oesophagus and skin.
- Delays beyond 24 hours are associated with a very high mortality rate.
A 75-year-old woman has suffered recurrent falls due to orthostatic hypotension. She has tried conservative measures such as taking in more fluid and salt. Her medications have been reviewed and some of her medications have been stopped. She has also tried wearing compression stockings. Nevertheless, she still suffers dizziness on standing up.
What is a possible medication option to reduce her symptoms?
Doxazosin
Prochlorperazine
Isoprenaline
Fludrocortisone
Dobutamine
Fludrocortisone
Management of orthostatic hypotension
- education and lifestyle measures such as adequate hydration and salt intake
- discontinuation of vasoactive drugs e.g. nitrates, antihypertensives, neuroleptic agents or dopaminergic drugs
- if symptoms persist, consider compression garments, fludrocortisone, midodrine, counter-pressure manoeuvres, and head-up tilt sleeping
How does fludrocortisone work in the context of orthostatic hypotension?
Fludrocortisone increases renal sodium reabsorption and increases the plasma volume. This helps to counteract the physiological orthostatic vasovagal reflex.
