78-year-old female who presents with crushing central chest pain for 20…
78-year-old female who presents with crushing central chest pain for 20 minutes.
Acute pulmonary embolism
Clinical signs and symptoms of DVT (i.e., objectively measured
leg swelling or pain with palpation of deep leg veins)
PE as likely or more likely than an alternative diagnosis
Heart rate more than 100 beats per minute
Immobilization (i.e., bedrest except for bathroom access
for at least three consecutive days) or surgery in the past
Previous objectively diagnosed DVT or PE
sudden onset of dyspnea and pleuritic chest pain. decreased chest excursion on the affected side, diminished breath sounds, and hyperresonant percussion.
Egophony, Dullness to percussion, Fever, Myalgia
Night sweats, Sputum all day, Respiratory rate more than
25 breaths per minute
pressure, heaviness, tightness, or constriction in the center or left of the chest that is precipitated by exertion and relieved by rest. not described as pain (sharp or dull), ache, or needles and pins.
Patient often indicates the entire chest
Age greater than 60 years
History of MI or angina
Pain described as pressure
Pain radiating to arm, shoulder, neck, or jaw
continuous cardiac monitoring, oxygen, and intravenous access. Therapy should be started to relieve ischemic pain, stabilize hemodynamic status, and reduce ischemia
●Initiation of reperfusion therapy with primary percutaneous coronary intervention (PCI) or fibrinolysis
●Antithrombotic therapy to prevent rethrombosis or acute stent thrombosis
●Beta blocker therapy to prevent recurrent ischemia and life-threatening ventricular arrhythmias
●Antiplatelet therapy to reduce the risk of recurrent coronary artery thrombosis or, with PCI, coronary artery stent thrombosis.
●Angiotensin converting enzyme inhibitor therapy to prevent remodeling of the left ventricle
Acute Aortic Dissection
pain is severe, sharp/knife-like, categorically unlike any pain experienced before. It can radiate anywhere in the thorax or abdomen. PE: heart murmur, (diastolic decrescendo murmur associated with a wide pulse pressure) upper limb pulse deficit, Syncope, hypotension, and/or shock at initial presentation are more common in patients with ascending aortic dissection, whereas hypertension is more common in patients with descending aortic dissection
sharp and pleuritic in nature, with exacerbation by inspiration or coughing.
-Pericardial friction rub – A superficial scratchy or squeaking sound best heard over the left sternal border
Electrocardiogram (ECG) changes – New widespread ST elevation or PR depression
fatigue, chest pain, heart failure, cardiogenic shock, arrhythmias, and sudden death , excessive fatigue or exercise intolerance, S3, S4, or summation gallop, Respiratory distress/tachypnea
stress (takotsubo) cardiomyopathy
triggered by intense emotional or physical stress (eg, death of relatives. chest pain, dyspnea, and syncope. Some patients: tachyarrhythmias (including ventricular tachycardia and ventricular fibrillation), bradyarrhythmias, sudden cardiac arrest, or significant mitral regurgitation
chest wall injuries
Palpation of tender area
reproduces chest pain
heartburn (pyrosis), regurgitation, and dysphagia. A variety of potential extraesophageal manifestations have also been described including bronchospasm, laryngitis, and chronic cough.
Upper abdominal pain or discomfort , epigastric pain, nausea, hematemesis