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Doc750 transfer:step 3 prison Topics: 53 Posts: 628	Nov 16, 2007 - 8:11 AM       #1 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 Forum Elite Topics: 56 Posts: 271	Nov 16, 2007 - 11:02 AM       #2 unstable angina....needs trop level in 12hrs....follow up angio....treat for ht and hyperchol
tamerbashir Forum Newbie Topics: 30 Posts: 304	Nov 16, 2007 - 3:13 PM       #3 unstable ANGINA -------------------- FREE ECG ! ST DEPRESSION I THINK I THINK THE CAUSE MAY BE NOT CRONARY DISEASE IT CAN BE REFLUX ?
cool doctor Forum Senior Topics: 1 Posts: 230	Nov 16, 2007 - 4:02 PM       #4 its unstable angina he needs ASA, NG, B blockers and propably heparin
Doc750 transfer:step 3 prison Topics: 53 Posts: 628	Nov 16, 2007 - 6:47 PM       #5 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.
Vietnamese Forum Newbie Topics: 20 Posts: 301	Nov 19, 2007 - 11:41 PM       #6 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...
Vietnamese Forum Newbie Topics: 20 Posts: 301	Nov 23, 2007 - 12:42 AM       #7 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.
dr19 Forum Newbie Topics: 39 Posts: 235	Nov 25, 2007 - 6:06 AM       #8 Good observation
Vietnamese Forum Newbie Topics: 20 Posts: 301	Nov 25, 2007 - 7:59 AM       #9 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.
sherry39 Forum Senior Topics: 3 Posts: 104	Feb 29, 2008 - 5:52 AM       #10 it may be due to aortic dissection
anuba Forum Elite Topics: 6 Posts: 444	Feb 29, 2008 - 6:10 AM       #11 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.
hope4dabest Forum Guru Topics: 23 Posts: 456	Mar 10, 2008 - 9:51 AM       #12 Aortic dissection cannot be said sure from just this info... I thought GERD first BUT then as vietnamese pointed out the nitroglycerin effect
hope4dabest Forum Guru Topics: 23 Posts: 456	Mar 10, 2008 - 9:53 AM       #13 Hey by the way nitroglycerin is a dilator of BLOOD VESSELS , what effect will it have on esophagus ???
nyimalay Forum Elite Topics: 11 Posts: 298	Mar 10, 2008 - 10:25 AM       #14 Nitroglycerin causes smooth muscle relaxation. In oesophagus it, - worsen GERD because of LES relaxation - relieve pain in nut-cracker oeso/ diffuse oeso. spasm
lampard Forum Senior Topics: 8 Posts: 105	Mar 10, 2008 - 8:21 PM       #15 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.
lampard Forum Senior Topics: 8 Posts: 105	Mar 10, 2008 - 8:23 PM       #16 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
dr19 Forum Newbie Topics: 39 Posts: 235	Apr 19, 2010 - 4:16 PM       #17 I suggest a Stress ECG before treatment.
tompat Forum Newbie Topics: 64 Posts: 561	Apr 19, 2010 - 8:16 PM       #18 i think we shud do cardiac biomarkers first to r/o NSTEMI. if negative then the dia. is unstable angina(because its new onset angina). these pt. are not to be takes foe stress ECG as UA is a contraindication for stress ECG. after giving all medicines for acute coronary syndrome, he shud be taken for angiography.
alirizvi Forum Newbie Topics: 36 Posts: 542	Apr 24, 2010 - 9:48 AM       #19 lol this guy is def not having gerd if a person has nitroglycerin at home then there is a reason for that main thing for this guy is UA VS NSTEMI. Treat with MONA then get cardiac enzymes 4-6hrs from onset. Also can add heparin if u risk stratify this guy for risk of having adverse cardiac event in next 2 weeks. if enzyme + then angiogram -> pci/cabg etc if enzyme - risk stratify with stress ekg ( tompat i think u can run after having UA just that the target HR has to be 70% of normal target i know its not sensitive but its cheap ) if thats + then angiogram --> pci/cabg etc

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