Hospital HIMA-San Pablo

MEDICAL INTERNSHIP

IM WARD CASE
PRESENTATION
CHEST PAIN
JUAN G RAMIREZ, MI
CAMILLE DEL PILAR, MI

HISTORY OF PRESENT
ILLNES
72 y/o M with PMHx back and cervical pain.
No meds.
07/17/15- Epigastric Pain.
L:middle
chest
07/18/15- 1ST ER visit: Troponin NEG

of

the

I: 6 of 10
Q: oppressive
O: 2 days ago
R: Both shoulders
A/A: none
A: Epigastric pain

EKG NEG
RX NEG
07/19/15- 2ND ER visit: Chest Pain

No nausea, no vomits

PHYSICHAL
EXAMINATION
GEN: AAOx3, Mild Distress, Antialgic position Afebrile
VS: RR= , HR= , BP=
, Temp=
HEEENT: WNL.
NECK: mild discomfort on movement.
CHEST: CTAx2, Parasternal superficial tenderness(2 nd

day).
HEART: RRR, NEW Murrmur(3rd day), no Galop, no Rubs.
Abdomen: BS+, Mild Epigastric Tenderness, no masses.
Extremities: WNL.
Neuro: WNL.

LABORATORIES
TROPONIN I- NEG x30.12 0.21
CK-MB: neg
.

Chest X Ray

DIFFERENTIAL
DIAGNOSIS
Commons:

-VS-

Acute coronary

syndrome
Stable angina
Pulmonary embolism
Pneumonia
Viral pleuritis
GORD
Costochondritis
Anxiety/panic
disorder

Uncommons:
Pericarditis
Cardiac tamponade
Aortic dissection
Aortic stenosis
Mitral valve prolapse
Pneumothorax
Pulmonary hypertension
Peptic ulcer disease
Oesophageal spasm
Acute cholecystitis
Pancreatitis
Herpes zoster
Gastritis

Acute coronary syndrome

HPI: central chest pressure, squeezing, or heaviness;

radiation to jaw or upper extremities; associated

nausea, vomiting, dyspnea, dizziness, weakness;
occurs at rest or accelerating tempo (crescendo);
Risk factors: smoking, age (men >45, women
>55),FHx of premature CAD,HTN, hyperlipidemia,
diabetes, stroke, or peripheral arterial disease[7][8]
Exam:examination may be normal; JVD, S4 gallop,
holosystolic murmur (mitral regurgitation), bibasilar
rales; hypotensive, tachycardic, bradycardic, or
hypoxic depending on severity of ischaemia[7][8]

ACS
1st-TEST
ECG:ST-elevation MI (STEMI): ST-segment elevation >1 mm in 2

anatomically contiguous leads or new left bundle-branch block; nonST-elevation MI (NSTEMI) or unstable angina: non-specific; STsegment depression or T-wave inversion
cardiac enzymes:elevated in STEMI and NSTEMI; not elevated in
unstable angina
CXR:normal or signs of heart failure, such as increased alveolar
markings.

2st- Tests
coronary angiography:STEMI: critical occlusion of a coronary
artery; NSTEMI and unstable angina: evidence of coronary artery
narrowing
BNP:>99th percentile of normal

Stable angina
HPI: central chest pressure, squeezing, or heaviness;

radiation to jaw or upper extremities; associated

nausea, vomiting, dyspnea, dizziness, weakness;
occurs at rest or accelerating tempo (crescendo);
Risk factors: smoking, age (men >45, women >55
years), positive FHx of premature CAD,
hypertension, hyperlipidemia, diabetes, stroke, or
peripheral arterial disease[8]
Exam: no specific findings for CAD, may have
abnormal pulses if peripheral vascular disease
present.

Stable angina
1st test:
ECG:no acute changes; may have evidence of previous
infarction, such as Q waves
CXR:normal or cardiomegaly
cardiac biomarkers:not elevated
Other tests:
stress testing:1 mm of horizontal or down-sloping ST-

segment depression or ST-segment elevation during or after

exercise is considered positive for ischemia; high-risk disease:
regional wall motion abnormalities and left ventricular
dysfunction
coronary angiography:evidence of coronary artery narrowing
CT coronary angiography: identification of stenosis

Pulmonary embolism
HPI: sharp and pleuritic in nature; shortness of breath;

haemoptysis may occur if pulmonary infarction

develops; massive PE results in syncope; risk factors:
history of immobilisation, orthopedic procedures, oral
contraceptive use, previous PE, hypercoagulable states,
or recent travel over long distances;[32]unilateral
swollen lower leg that is red and painful suggests DVT;
use of the modified Wells criteria can help to screen for
risk factors and clinical features suggesting high
probability[33]
Exam: tachycardia, loud P2, right-sided S4 gallop,
jugular venous distention, fever, right ventricular lift;
massive PE may cause hypotension

PE
1st test
ECG:sinus tachycardia; presence of S1, Q3, and T3
D-dimer:non-specific if positive; PE excluded if result negative in
patients with low probability of having a PE
CXR:decreased perfusion in a segment of pulmonary vasculature
(Westermark sign); presence of pleural effusion
CT pulmonary angiography: identification of thrombus in the
pulmonary circulation
Others Test:
echocardiography:acute right ventricular dilation or hypokinesis
V/Q scan :V/Q mismatch
pulmonary angiography: identification of thrombus in the

pulmonary circulation

Pneumonia
History productive or dry cough, fever, pleuritic pain associated with

shortness of breath; may have rigors, myalgias, and arthralgias;

recent history of travel or infectious exposures[34]
Exam: decreased breath sounds, rales, wheezing, bronchial breath
sounds, dullness to percussion, and increased tactile fremitus
observed with severe consolidation[34]
1st test:
CXR:pulmonary infiltration, air bronchograms, and pleural effusion

Other tests:
WBC count:elevated with left shift (increased neutrophil count)
sputum culture:may reveal culprit organisms, but not sensitive or
specificMore
blood culture:may reveal culprit organisms, but not sensitive or
specific

Viral pleuritis
History prodrome of viral illness (myalgias, malaise,

rhinorrhoea, cough, nasal congestion, low-grade

temperatures); sick contacts
Exam: pleural friction rub with or without low-grade
fever; sometimes reproducible tenderness to palpation
of chest when perichondritis or pleurodynia
accompanies pleuritis
1st test:
CXR:usually normal but can uncommonly have effusion

Other tests :
FBC:normal, or leukocytosis with lymphocytic
predominance

GERD
History retrosternal burning with eating large or fatty

meals that can be reproduced with lying supine and

relieved by sitting up; relieved by antacids[37]
Exam: no specific physical findings
1st test:
therapeutic trial:relief of symptoms with short trial of

proton-pump inhibitors

Other tests:
Oesophagogastroduodenoscopy: oesophageal

inflammation or erosions
oesophageal pH monitoring: persistently low pH
(<4) may indicate reflux disease

Costochondritis
History focal chest wall pain, may have known

precipitating injury; aggravated by sneezing,

coughing, deep inspiration, or twisting of the
chest
Exam: reproducible pain, especially at the
costochondral junctions
1st test
CXR:no specific findings. (R/O Fractures and

malignacies)

Other tests

Anxiety or panic disorder

History: sharp chest pain with anxiety, dizziness or

faintness, palpitations, sweating, trembling or shaking,

fear of dying or going insane, paraesthesiae, chills or
hot flushes, breathlessness or choking sensation
Exam: hyperventilation, examination otherwise normal
1st test:
ECG:normal

Other tests:
CXR:normal
HADS (hospital anxiety and depression scale)
score:score >11

Consult to Cadiology
Pt.

Risk
factors
Age,
Hypercholesterolemia,
ACS Dx. Excluded
Patient presentation is unlikely due to a
cardiac event, pain description does not
indicate a cardiovascular etiology. Diagnostic
evaluations are negative. The only sugestive
risk factors are the age, cholesterol levels and
HTN.

Management
Severe pain (due to costochondritis, Tietze's syndrome,

sternoclavicular or manubriosternal arthritis)

Best managed with a local injection of a mixture of

corticosteroids and local anesthetic. Ultrasound guidance

may be needed for joint aspiration or injection.
If the treating clinician is not experienced in the injection
technique for these disorders, and consultation with a
rheumatologist, orthopedist, or pain-management specialist
is not immediately available, then one of the following
alternatives may be employed while the patient awaits an
appointment for a local injection:
Prescription-strength NSAIDs
Parenteral, followed by oral, ketorolac
Short-term use of a short-acting narcotic analgesic such as codeine

Reference articles
1.Niska R, Bhuiya F, Xu J. National hospital ambulatory medical care survey: 2007 emergency department summary. Nat Health Stat Report. 2010;26:1-31.

Full Text(external link)Abstract(external link)

2.Hsiao CJ, Cherry DK, Beatty PC, et al. National ambulatory medical care survey: 2007 summary. Natl Health Stat Report. 2010;(27):1-32.

Full Text(external link)Abstract(external link)

3.Ruigomez A, Rodriguez LA, Wallander MA, et al. Chest pain in general practice: incidence, comorbidity and mortality. Fam Pract. 2006;23:167-174.

Full Text(external link)Abstract(external link)

4.Klinkman MS, Stevens D, Gorenflo DW. Episodes of care for chest pain: a preliminary report from MIRNET. Michigan Research Network. J Fam Pract. 1994;38:345-352.

Abstract(external link)
5.Kohn MA, Kwan E, Gupta M, et al. Prevalence of acute myocardial infarction and other serious diagnoses in patients presenting to an urban emergency department with chest pain. J Emerg Med. 2005;29:383-390.

Abstract(external link)
6.Davis T, Bluhm J, Burke R, et al; Institute for Clinical Systems Improvement. Diagnosis and treatment of chest pain and Acute Coronary Syndrome (ACS). November 2012. https://www.icsi.org/ (last accessed 24 October 2014).

Full Text(external link)

7.O'Gara PT, Kushner FG, Ascheim DD, et al. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;127:e362-e425.

Full Text(external link)Abstract(external link)

8.Anderson JL, Adams CD, Antman EM, et al. ACC/AHA 2007 guidelines for the management of patients with unstable angina/non ST-elevation myocardial infarction. Circulation. 2007;116:e148-e304.

Full Text(external link)Abstract(external link)

9.Task force on the management of ST-segment elevation acute myocardial infarction of the European Society of Cardiology (ESC); Steg PG, James SK, Atar D, et al. ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2012;33:2569-2619.

Full Text(external link)Abstract(external link)

10.Konstantinides SV, Torbicki A, Agnelli G, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014 Aug 29 [Epub ahead of print].

Full Text(external link)Abstract(external link)

11.American Heart Association. Acute coronary syndromes. Circulation. 2005;112:III-55-III-72.

Full Text(external link)

12.Swap CJ, Nagurney JT. Value and limitations of chest pain history in the evaluation of patients with suspected acute coronary syndromes. JAMA. 2005;294:2623-2629.

Full Text(external link)Abstract(external link)

13.National Cholesterol Education Program Expert Panel on Detection, Evaluation, and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III). Third report of the National Cholesterol Education Program (NCEP) Expert Panel on detection, evaluation, and treatment of high blood cholesterol in adults (Adult Treatment Panel III): final report. September 2002. http://www.nhlbi.nih.gov/ (last accessed 24 October 2014).

Full Text(external link)

14.McCord J, Jneid H, Hollander JE, et al; American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Management of cocaine-associated chest pain and myocardial infarction: a scientific statement from the American Heart Association Acute Cardiac Care Committee of the Council on Clinical Cardiology. Circulation. 2008;117:1897-1907.

Full Text(external link)Abstract(external link)

15.NewAmerican College of Radiology. ACR appropriateness criteria: chest pain suggestive of acute coronary syndrome. 2014. http://www.acr.org/ (last accessed 27 October 2014).

Full Text(external link)

16.NewWolk MJ, Bailey SR, Doherty JU, et al; American College of Cardiology Foundation Appropriate Use Criteria Task Force. ACCF/AHA/ASE/ASNC/HFSA/HRS/SCAI/SCCT/SCMR/STS 2013 multimodality appropriate use criteria for the detection and risk assessment of stable ischemic heart disease. J Am Coll Cardiol. 2014;63:380-406.

Full Text(external link)Abstract(external link)

17.NewAmerican College of Radiology. ACR appropriateness criteria: acute chest pain - suspected aortic dissection. 2014. http://www.acr.org (last accessed 24 October 2014).

Full Text(external link)

18.Wang WH, Huang JQ, Zheng GF, et al. Is proton pump inhibitor testing an effective approach to diagnose gastroesophageal reflux disease in patients with noncardiac chest pain?: a meta-analysis. Arch Intern Med. 2005;165:1222-1228.

Full Text(external link)Abstract(external link)

19.Jeremias A, Gibson CM. Narrative review: alternative causes for elevated cardiac troponin levels when acute coronary syndromes are excluded. Ann Intern Med. 2005;142:786-791.

Abstract(external link)
20.Task Force for Diagnosis and Treatment of Non-ST-Segment Elevation Acute Coronary Syndromes of European Society of Cardiology, Bassand JP, Hamm CW, et al. Guidelines for the diagnosis and treatment of non-ST-segment elevation acute coronary syndromes. Eur Heart J. 2007;28:1598-1660.

Full Text(external link)Abstract(external link)

21.Gibbons RJ, Balady GJ, Bricker JT, et al. ACC/AHA 2002 guideline update for exercise testing: summary article: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines). Circulation. 2002;106:1883-1892.

Full Text(external link)Abstract(external link)

22.Klocke FJ, Baird MG, Lorell BH, et al. ACC/AHA/ASNC guidelines for the clinical use of cardiac radionuclide imaging--executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/ASNC Committee to Revise the 1995 Guidelines for the Clinical Use of Cardiac Radionuclide Imaging). J Am Coll Cardiol. 2003;42:1318-1333.

Abstract(external link)
23.Smeeth L, Skinner JS, Ashcroft J, Hemingway H et al; Chest Pain Guideline Development Group. NICE clinical guideline: chest pain of recent onset. Br J Gen Pract. 2010 Aug;60(577):607-10.

Abstract(external link)
24.Henderson RA, O'Flynn N; on behalf of the Guideline Development Group. Management of stable angina: summary of NICE guidance. Heart. 2012 Jan 23.

Abstract(external link)
25.Roberts WT, Bax JJ, Davies LC. Cardiac CT and CT coronary angiography: technology and application. Heart. 2008;94:781-792.

Abstract(external link)
26.Chow BJ, Larose E, Bilodeau S, et al. The 'what, when, where, who and how?' of cardiac computed tomography in 2009: guidelines for the clinician. Can J Cardiol. 2009;25:135-139.

Full Text(external link)Abstract(external link)

27.Lange RA, Hillis LD. Clinical practice: acute pericarditis. N Engl J Med. 2004;351:2195-2202.

Abstract(external link)
28.Tsai TT, Nienaber CA, Eagle KA. Acute aortic syndromes. Circulation. 2005:112;3802-3813.

Full Text(external link)Abstract(external link)

29.Meszaros I, Morocz J, Szlavi J, et al. Epidemiology and clinicopathology of aortic dissection. Chest. 2000;117:1271-1278.

Abstract(external link)
30.von Kodolitsch Y, Nienaber CA, Dieckmann C, et al. Chest radiography for the diagnosis of acute aortic syndrome. Am J Med. 2004;116:73-77.

Abstract(external link)
31.Carabello BA. Clinical practice. Aortic stenosis. N Engl J Med. 2002;346:677-682.

Abstract(external link)
32.Piazza G, Goldhaber SZ. Acute pulmonary embolism: part I: epidemiology and diagnosis. Circulation. 2006;114:e28-e32.

Full Text(external link)Abstract(external link)

33.Wells PS, Anderson DR, Rodger M, et al. Derivation of a simple clinical model to categorize patients' probability of pulmonary embolism: increasing the model's utility with the SimpliRED D-dimer. Thromb Haemost. 2000;83:416-420.

Abstract(external link)
34.Lutfiyya MN, Henley E, Chang LF, et al. Diagnosis and treatment of community-acquired pneumonia. Am Fam Physician. 2006;73:442-450.

Full Text(external link)Abstract(external link)

35.Sahn SA, Heffner JE. Spontaneous pneumothorax. N Engl J Med. 2000;342:868-874.

Abstract(external link)
36.McGoon M, Gutterman D, Steen V, et al. Screening, early detection, and diagnosis of pulmonary arterial hypertension: ACCP evidence-based clinical practice guidelines. Chest. 2004;126(suppl 1):14S-34S.

Full Text(external link)Abstract(external link)

37.Smith L. Updated ACG guidelines for diagnosis and treatment of GERD. Am Fam Physician. 2005;71:2376-2382.

Full Text(external link)

38.Saad RJ, Scheiman JM. Diagnosis and management of peptic ulcer disease. Clin Fam Pract. 2004;6:569-587.
39.Vilaichone RK, Mahachai V, Graham DY. Helicobacter pylori diagnosis and treatment. Gastroenterol Clin North Am. 2006;35:229-247.

Abstract(external link)
40.Saud BM, Szyjkowski RD. A diagnostic approach to dysphagia. Clin Fam Pract. 2004;6:525-546.
41.Flasar MH, Cross R, Goldberg E. Acute abdominal pain. Prim Care. 2006;33:659-684.

Abstract(external link)
42.Billittier AJ, Abrams BJ, Brunetto A. Radiographic imaging modalities for the patient in the emergency department with abdominal complaints. Emerg Med Clin North Am. 1996;14:789-850.

Abstract(external link)
43.Kadakia SC. Biliary tract emergencies. Acute cholecystitis, acute cholangitis, and acute pancreatitis. Med Clin North Am. 1993;77:1015-1036.

Abstract(external link)
44.Mayerle J, Simon P, Lerch MM. Medical treatment of acute pancreatitis. Gastroenterol Clin North Am. 2004;33:855-869.

Abstract(external link)
45.Keim V, Teich N, Fiedler F, et al. A comparison of lipase and amylase in the diagnosis of acute pancreatitis in patients with abdominal pain. Pancreas. 1998;16:45-49.

Abstract(external link)