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| | Clinical Vignette A clinical vignette is a concise presentation of an interesting or challenging patient encounter that stimulated an interesting learning issue. |  | Senior Member | | Posts: 127 Thanks: 0
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Join Date: May 2006 Location: China | | | Chest pain in a 65-yr-old man -
27-05-2006, 07:12 AM
Hello frens,
I am presenting a case here. A 65 year old man came to the hospital with chest pain lasting for more than 1 hour. He is hypertensive (190/100 at the time of presentation) and diabetic. ECG is normal (WNL). He says pain was very severe in onset,now feeling better but still having chest pain. What other physicals you look and what investigations will you order? What is your D/D? If you were doc-in-charge what medications whould you suggest at this time?
Looking for ur opinion...
C ya | | The Following User Says Thank You to Soul For This Useful Post: | |  | Member | | Posts: 90 Thanks: 0
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Join Date: Oct 2005 Location: NEPAL | | |
27-05-2006, 07:55 AM
If I am right, it looks like a case of Unstable (cresendo) angina
Investigations: Serum Troponins, Serum LDH, Serum CKMB, Serum SGOT
Differential: Acute M.I, Pericardial effusion, Hyperkalaemia, Cardiac tamponade
Medications: Sublingual nitroglycerine, Aspirin to chew, Cardioselective Beta Blocker (Atenolol)
Please correct me if I am wrong.
"To deeds alone hast thou a right and never at all to its fruits, let not the fruits of deeds be thy motive, neither let there be in thee any attachment to non performance."
Last edited by Arjun; 27-05-2006 at 07:58 AM.
| | The Following User Says Thank You to Arjun For This Useful Post: | | | Senior Member | | Posts: 127 Thanks: 0
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Join Date: May 2006 Location: China | | |
27-05-2006, 08:08 AM
The most important feature of this case is an understanding of a logical approach to the chest pain in a man with a H/O hypertension and diabetes. If you do everything correctly, you will make the right diagnosis. I will post the final diagnosis after few days. Keep posting your opinion. | | The Following User Says Thank You to Soul For This Useful Post: | | | Senior Member | | Posts: 127 Thanks: 0
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27-05-2006, 10:02 PM
Arjun, you are in right track...need broad thinking here. Your D/D are not sufficient. You might be missing something blunder. I haven't posted lab values and other investigations, just wanna see how you guys deal with this case. I will post the Dx very soon with explanations.
Remember hyperkalemia might cause ST-elevation in ecg but is not a cause of acute chest pain. | | The Following User Says Thank You to Soul For This Useful Post: | | | New Member | | Posts: 11 Thanks: 0
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Join Date: Apr 2006 | | |
28-05-2006, 12:36 PM
Hey !
I guess its MI coz de duration of pain is more then 1hs unlike in angina its always <30 mins isn't it.For investigation,ambulatory ECG sud be done,serum CKMB n total CK,serum troponin,AST,LDH.
For de D/D:aortic dissection,oesophageal spasm,pneumothorax,pulmonary embolus,pericarditis,musculoskeletal,herpes zoster,anxiety etc.
Medication:analgesics like morphin to relieve the pain if not then nitrates..beta blockers,streptokinase
lokin forward to know de whole | | The Following User Says Thank You to Psychic For This Useful Post: | | | Senior Member | | Posts: 127 Thanks: 0
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Join Date: May 2006 Location: China | | | Solution -
28-05-2006, 08:15 PM
You guys are in right track. Let me elaborate this case. This patient came to our hospital 1 month back while I was in cardio dept. He complained of severe, sharp chest pain radiating towards back. ER doc did ECG,ordered for CXR and sent blood for lab analysis. In the mean time morphine, nitrates,aspirin, clopidogrel and LMWH was given thinking that this might be a case of UA/NSTEMI. But the patient's condition worsen.Immediately he was sent to CCU,I was there. Urgent bedside echo was done which showed aortic dissection (AD). Beta-blocker, CCB and iv nitroprusside were given. Patient's condition improved gradually. Next day CT showed Debakey type III AD.
I presented this case here just to let you know that AD should be in your DD list to every patient with acute chest pain. Thrombolytics given in this case (when misdiagnosed as MI) may lead to death of patient. In one study it was shown that 71% of patient will die of cardiac tamponade if AD is treated with thrombolytics.
Aortic dissection is very common in China. During my posting in cardio ward, I got to see 9 cases of AD in 2 months. Causes are hypertension, old age, Marfan syndrome, connective tissue disorder, bicuspid aortic valve etc.. The most important is hypertension. My doc used to say me if a patient with uncontrolled hypertension comes to you with sudden severe chest pain then think of AD first. Chest pain in AD is very severe and sharp which may radiate to the back. Treatment of AD is to reduce BP and heart rate. First line drugs are Beta-blockers and CCB. For the acute reduction of BP, sod.nitroprusside is very effective.
Conclusion of this case: AD is very dangerous with high mortality. So, D/D list MUST include AD in EVERY patient with chest pain. Cheers!!!  | | The Following User Says Thank You to Soul For This Useful Post: | | | Member | | Posts: 90 Thanks: 0
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28-05-2006, 11:19 PM
Quote: |
Originally Posted by Soul Arjun, you are in right track...need broad thinking here. Your D/D are not sufficient. You might be missing something blunder. I haven't posted lab values and other investigations, just wanna see how you guys deal with this case. I will post the Dx very soon with explanations.
Remember hyperkalemia might cause ST-elevation in ecg but is not a cause of acute chest pain. | Sorry Sir, I am extremely sorry for my mistake.
"To deeds alone hast thou a right and never at all to its fruits, let not the fruits of deeds be thy motive, neither let there be in thee any attachment to non performance." | | The Following User Says Thank You to Arjun For This Useful Post: | | | New Member | | Posts: 11 Thanks: 0
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29-05-2006, 01:28 AM
That's good job.You know actually i was confused regarding high BP which ain't de significant c/f of MI instead de BP is lower causing shock n u helped me through it...thankx
hope u'll share ur knowledge n experience in coming days too. | | The Following User Says Thank You to Psychic For This Useful Post: | | | Thread Tools | Search this Thread | | | | | Display Modes |  Linear Mode | 
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