Differential of The Chest Pain - Keluhan paling sering utk Penyakit Jantung - Tapi banyak Non Cardiac

History sangat penting

Terus menerus/kadang-kadang Lamanya Posisi Tubuh Pemicu : exercise, emosi, Food, posture, movement, breathing PenjalaranKwalitas : crushing, burning, stabbing

PJKGastric problemPost Operasi ThoraxPericarditisHipertensi, DM

System InvolvedPathologyCardiacMyocardial InfarctionAngina PectorisPericarditisProlapse of the mitral valveVascularAortic dissectionRespiratory (all tend to give rise to pleuritic pain)Pulmonary embolusPneumoniaPneumothoraxPulmonary neoplasmGastro IntestinalOesophagitis due to gastric refluxOesophageal tearPeptic UlcerBiliary diseaseMusculoskeletalCervical nerve root compression by cervical discCostochondritisFractured ribNeurologicalHerpes Zoster

Inspeksi : Shock : pucat, keringat myocardial infarction dissecting aorta pulmonal embolism Nafas tampak berat heart failure Mual, muntah gastric problem Batuk heart failure, pneumonia

Pulse & blood pressure : hipo & hipertensi, bradycardia, tachicardia, irreguler pulse Pucat, Cyanosis JVP (jugular venous pressure) Carotid pulse waveform Apex cardis Pericardial rub, S III, murmur

CharacteristicMyocardial ischemiaPericarditisPleuritic painGastrointestinal painMusculoskeletalAortic DissectionQuality of painCrushing, tight or bandlikeSharp (may be crushing)SharpBurningUsually sharp although can be a dull acheSharp, stabbing, tearingSite of painCentral anterior chestCentral anteriorAnywhere (usually very localized pain)CentralCan be anywhereRetrosternal, interscapularRadiationTo throat, jaw or armsUsually no radiationUsually no radiationTo throatTo arms or around chest to backUsually no radiationExacerbating & relieving factorsExacerbated by exertion, anxiety, cold, relieved by rest & by gliceryl trinitrateExacerbated when lying back; relieved by sitting forwardExacerbated by breathing, coughing or moving; relieid when breathing stopsPeptic ulcer pain often relieved by food & antacids; cholecystitis & oesophageal pain are exacerbated by foodCan be exacerbated by pressing on chest wall or moving neckConstant with no exacerbating or relieving factorsAssociated featurePatient often sweaty, breathless & shocked, might feel nauseatedFever, recent viral illness (e.g. rash, athralgia)Cough, haemoptysis, breathlessness;shock with pulmonary embolusExcessive windOther affected joints; patient otherwise looks very wellUnequal radial & femoral pulse & blood pressure; aortic regurgitant murmur may be heard on auscultation

Neckcarotiud waveformelevated JVPand waveform

BPhypotension (shock)hypertensiondifferent between extremitiesPulsearrhythmia (tachy- or brady- )difference between extremitiesAbdomenabdominal tenderness or guardingreduced bowel soundsLungspleural rubbronchial breathingreduced breath soundsHeartmurmur of AR (dissection) or AS (angina)pericardial rubaudible murmur of MR (MI)3rd heart sound (MI & LVF)right ventricular heave & loud P2 (pulmonary embolus)displaced apex beatFacepallor (anaemia)cyanosis eyes xanthelasma (hypercholesterolaemia)

D LCardiac biomarkers : CKMB, Troponin TFungsi RenalBlood GasLFT (liver function tests)

EKG Thorax Foto Echocardiography CT Scan MRI Exercise tolerance test

TestDiagnosisECGIf normal excludes MI, although evidence for this may emerge upon observationCXRWidened mediastinum suggest aortic dissection, may show pleural effusion or pulmonary consolidationBiochemical markersMay be normal in first 4 hour after MI, but CK-MB, cardiac troponins will then increaseArterial blood gasesIn the dyspnoeic patient severe hypoxaemia suggest pulmonary embolus, LVF or pneumoniaCT scanCarry out urgently for suspected aortic dissection

CK-MB, creatine kinase compose of M (muscle) & B (brain) subunits, which is found primarily in cardiac muscle; CT, computed tomography; CXR, chest radiography; ECG, electrocardiography; LVF, left ventriculer failure; MI, myocardial infarction

Chest painMusculoskeletal shingles (herpes zoster)Worse on exertionLateralMusculoskeletal oesophagitisCentral painPericarditisWidespread concave ST elevationConsider unstable angina and investigate further (i.e. serial ECGs, serial biochemical markers, excersie, coronary angiogramST depression T Wave inversion T Wave flatteningConsider MIRaised ST segmentPleurisy scondary to pneumonia,pneumothorax, pulmonary embolus, dresslers syndromeInvestigate for angina pectoris (i.e. serial ECG, coronary angiogram)Not worse in inspirationWorse in inspirationConsider pulmonary embolus in all patientsAt rest

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