Doc750
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A 60 year old man with a past medical history of HTN and high cholesterol presents to the ER complaining of "crushing" substernal chest pain, which began earlier that evening while he was lying on his couch watching tv. He states that his pain was not relieved with several sublingual nitroglycerin. In the ER, the patient is now pain free. His PE and ECG are within normal limits.
1) What is the diagnosis?
2) How would you treat this patient?
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| darkhorse
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unstable angina....needs trop level in 12hrs....follow up angio....treat for ht and hyperchol
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| tamerbashir
Forum Elite
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unstable ANGINA -------------------- FREE ECG !
ST DEPRESSION I THINK
I THINK THE CAUSE MAY BE NOT CRONARY DISEASE
IT CAN BE REFLUX ?
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| cool doctor
Forum Junior
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its unstable angina
he needs ASA, NG, B blockers and propably heparin
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| Doc750
transfer:step 3 prison
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1) Unstable angina
2) Tx: hospitilization and continuous ECG monitoring. Pharmacological tx IV heparin for 3-5 days followed by aspirin. IV nitroglycerin to relieve chest pain. CCB, BB, oral nitrates should also be given.
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| Vietnamese
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1- GERD, a small trick: his chest pain not relating to exertion, stress, even his pain get worsened as sublingual Nitroglycerine.
2- PPIs, avoid late-night meal...
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| Vietnamese
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Hi buddies,
Sublingual Nitroglycerine make patien worsened in GERD due to much more dilated LES, then he get normal back over time when Nitroglycerine empty. Note that his chest pain is not related to stress, exertion and just angina on lying appropriate for GERD.
1- How can you make a differencial diagnosis between GERD and Unstable Angina in this case? Please comment this case back, buddies.
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| dr19
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Good observation
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| Vietnamese
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Remember that some MCQs (10-20%) in USMLE is not taken score. Maybe this question is one case ilke that, I mean it is the experimental question.
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| sherry39
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it may be due to aortic dissection
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| anuba
Forum Elite
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I was thinking of Aortic Dissection also. It came to mind when I read a suit against 2 doctors, who treated John Ritter as MI not Aortic Dissection.
pt. here has HTN & Hyperchol. & crushing chest pain not relieved by Nitro.
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| hope4dabest
Forum Elite
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Aortic dissection cannot be said sure from just this info...
I thought GERD first BUT then as vietnamese pointed out the nitroglycerin effect
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| hope4dabest
Forum Elite
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Hey by the way nitroglycerin is a dilator of BLOOD VESSELS , what effect will it have on esophagus ???
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| nyimalay
Forum Elite
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Nitroglycerin causes smooth muscle relaxation.
In oesophagus it,
- worsen GERD because of LES relaxation
- relieve pain in nut-cracker oeso/ diffuse oeso. spasm
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| lampard
Forum Newbie
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HI friends,
here are my 2 cents :
There is now way we can differentiate between UA and MI by history. PE and a baseline EKG. SO calling it an unstable angina and treating accordingly would be a huge risk.
According to my knowledge for such a patient the protocol goes like
pt with chest pain => baseline EKG => if normal then a stress EKG => if normal again the cause is a non cardiac one most likely to be a GI, if the EKG shows ST depression then UA, if the EKG shows ST elevation then its MI.
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| lampard
Forum Newbie
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this patient has non cardiaccause of chest pai, most likely to be GERD since the pain wasn't improved with NTG.
Treatment would be antacids
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