Personalised Discussions: Let us manage this clinical case

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:stethoscope: Case : Chest Pain in a 55-Year-Old Man

“You’re all interns on duty. A 55-year-old male comes to the OPD complaining of chest pain. Let’s discuss.”

:speaking_head: Subjective Data (History Provided) Chief Complaint: Central chest pain for 2 hours.
History of Present Illness: Radiates to left shoulder and jaw.
Associated with sweating, nausea. Not related to meals or posture.
Past History: Hypertension, Type 2 Diabetes. Social History: Smoker (20 pack-years), occasional alcohol.

:busts_in_silhouette:Let’s discuss, more interesting?
1 answer per person in sequence but the answer of subsequent doctor should be comtinuation of previous given answer

History Taking
What more would you ask in the history?
How would you differentiate between cardiac and non-cardiac chest pain?

Differential Diagnosis
What are the top 3 possible diagnoses?
How do you rule out life-threatening conditions?

Investigations
What initial investigations would you order? What findings would confirm your diagnosis?

Assessment
Based on history, what’s your most likely diagnosis?
What scoring systems (e.g., TIMI score) might you use?

Plan
What is your immediate management plan?
How would you counsel the patient regarding lifestyle?

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Diagnosis may be acute coronary disorder (ACD) I.E. unstable angina and cause the nausea and sweating

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What lifestyle changes would specifically emphasize for a smoker with HTN and diabetes post-MI?

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3 diagnosis can be - acute coronary syndrome
Aortic dissection
Pulmonary embolism

Immediate management - MONA-B

Morphine
Oxygen
Nitroglycerin
Aspirin
B - blocker ( if no contraindication)

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Based on given history can we narrow down our diagnosis to ACS ??

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Diagnosis :-

*Acute Coronary Syndrome (ACS)
*Aortic Dissection
*Pulmonary Embolism (PE)

Investigation:-

  1. ECG
  2. Troponin I/T
  3. Chest X-ray
  4. Echo
  5. CBC
  6. lipid profile
  7. RBS
  8. D-dimer
  9. TIMI or HEART score
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What has been done in terms of the treatment so far? Was the patient offered any anti-anginals?

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diagnosis could be Acute Coronary Syndrome, immediate plan could be introducing MONA-B, advise could be - quitting smoking, proper diet

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History Taking
I’d ask about onset, character, and duration of pain; any relieving or aggravating factors; recent exertion or stress; family history of cardiac disease; and prior similar episodes.

Differential Diagnosis
Top 3: Acute Coronary Syndrome (ACS), Aortic Dissection, Pulmonary Embolism.
Life-threatening causes are ruled out by ECG, cardiac enzymes, chest X-ray, and D-dimer/CT angiogram.

Investigations
Order: ECG, troponin levels, chest X-ray, CBC, electrolytes, glucose, lipid profile.
ST-elevation or elevated troponins confirm MI; widened mediastinum suggests dissection; low oxygenation may point to embolism.

Assessment
Most likely diagnosis: Acute Coronary Syndrome.
TIMI score helps assess risk in unstable angina/NSTEMI; GRACE score also aids in mortality prediction.

Plan
Immediate: MONA (Morphine, Oxygen, Nitrates, Aspirin), IV access, cardiac monitoring.
Counseling: Quit smoking, control diabetes/BP, adopt heart-healthy diet, regular exercise, stress management, medication adherence.

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