Clinical Case

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Clinical Case Chest Pain

• Dr Michael Ramcharan
• Cleveland Chiropractic College
• Clinical Sciences and Diagnostic Division -
  Differential Diagnosis
• University of Kansas School of Medicine - Master
  Public Health Candidate

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Chest Pain
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POSSIBLE DX - DR RAMCHARAN

• Chest pain is categorized into 3 diagnostic
  groups
• Angina
• Atypical chest pain
• Noncardiac chest pain

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• Determine whether pain is of cardiac or
  noncardiac origin
• Categorize the chest pain as to which of the five
  organ systems are affected
• Cardiac disease
• Gastrointestinal disease
• Musculoskeletal disease
• Pulmonary disease
• Psychiatric disease

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• Cardiac disease
• Stable angina
• Unstable angina
• AMI
• Pericarditis
• Aortic dissection

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• GI disease
• Esophagitis/esopheageal dysmotility
• Gastric or duodenal ulcer
• Acute cholecystitis
• pancreatitis

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• MSK disease
• Costochondritis
• Rib subluxation
• Cervical spondylosis

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• Pulmonary disease
• COPD
• Asthma
• Pulmonary hypertension
• Pleurisy
• Pneumothorax
• Pulmonary embolism
• Pneumonia
• Lung cancer

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• Psychiatric disorders
• somatization
• Anxiety disorders
• Panic attacks
• Depression

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WISNIEWSKI Volume 3(4).July/August 2005.3741
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Sheps Psychosom Med, Volume 66(6).November/Decemb
er 2004.861-867
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QUESTIONS

• What important questions are you going to ask
  this patient?

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CASE 7

• In a rural setting in western Kansas, Dr. X was
  the only Chiropractic PC Physician within a 10
  miles radius, so a current patient, a 42 year
  old African American male followed up with Dr. X
  after a sudden onset of severe retrosternal chest
  pain that began an hour ago while he was at home
  mowing the lawn
• Based on the patients presentation, what are the
  7 most possible causes of the patients chest pain?

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POSSIBLE Diagnosis

• MI
• Angina
• Hiatal hernia
• GERD
• Costochondritis
• Rib subluxation
• PE
• Pericarditis
• Pneumothorax
• Indigestion
• Dissecting aneurysm

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HISTORY

• The 42 year old male describes the retrosternal
  chest pain as sharp, constant, stabbing pain and
  unrelated to movement, he says the pain radiates
  posterior to the shoulder blades
• It was not relieved by 3 doses of sublingual
  nitrogylcerin administered on route to your
  office
• He has never had symptoms like this before but
  has been under a tremendous amount of stress
  within the last 2 weeks
• PMHX indicated hypertension and no history of
  cardiac disease in the family except for Marfans
  Syndrome
• Only Rx taken is Enalapril for BP which is
  normally under control but recently ran out of
  Rx for past 4 days and not refilled Rx
• He does not smoke, drink alcohol or use illicit
  drugs
• He is a basketball coach at a local High School,
  very physical active

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• Based on the history, what are the most to least
  probable diagnosis for this patient now?

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WORKUP MI
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POPE Chest Pain, Volume 2(1).January/February
2004.819, 35
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WORKUP PE
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WORKUP GERD

• Aimed at eliminating the conditions noted in the
  differential diagnosis (Unstable Angina,
  Esophageal spams, Peptic Ulcers and esophagitis)
  and documenting the type and extent of tissue
  damage
• Upper GI endoscopy is useful to document the type
  and extent of tissue damage in GERD and to
  exclude potentially malignant conditions such as
  Barrett's esophagus
• The American College of Gastroenterology
  recommends endoscopy to screen for Barrett's
  esophagus in patients who have chronic GERD
  symptoms

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LABORATORY TESTS GERD

• 24-hr esophageal pH monitoring and Bernstein test
  are sensitive diagnostic tests however, they are
  not very practical and generally not done
• They are useful in patients with atypical
  manifestations of GERD, such as chest pain or
  chronic cough
• Esophageal manometry is indicated in patients
  with refractory reflux in whom surgical therapy
  is planned

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WORKUP AD
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Clinical case Physical exam

• A tall man with long arms and legs who appears
  uncomfortable and diaphoretic
• Afebrile
• HR 118
• BP 156/100 mmHg Rt arm and 188/94 mmHg Lt arm
• Head and neck is unremarkable
• Chest is clear to auscultation bilaterally
• Incidental note of pectus excavatum
• Heart rate is tachycardic and regular with a soft
  diastolic murmur at the right sternal border
• Abdomen is benign
• Neurological exam is nonfocal

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DIAGNOSTIC IMAGING

• Any diagnostic imaging or lab work you would like
  to order?
• Plain Film radiograph?
• EKG?
• CT? CT angiograph?
• MRI?
• TEE? transesophageal echocardiography
• Troponin I and T?
• CPK, CPK-MB, LHD?

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WORKING DIAGNOSIS

• What do you suspect is your working diagnosis?

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WORKING DIAGNOSISAortic Dissection Marfan
Syndrome
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Intraoperative view of an acute type A
dissection. One can clearly see the site of the
entry tear in the intima 1.5 cm above the aortic
valve (A)
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CT Scan showing a huge ascending aortic aneurysm
with a maximum diameter of 8.2 cm
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