Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

You know, for the presenting complaint and the working sort of backwards to see other conditions that cause it, the reason why this is really important for both your OSC S and A KT is because you'll be given a presenting complaint and it's quite easy to jump to the first thing that causes, oh, the first thing that comes to your mind. So for me, that's always a heart attack when I hear chest pain. Um And obviously that makes sense, heart attack is a massive condition. You wanna make sure you don't miss it. The thing is it's not always a heart attack and you wanna make sure you're getting all of the other differentials as well. You wanna make sure you ask questions to rule them in or out and you wanna make sure you're getting marks for that too. Um So that's why I think this talk is quite good. So some people tend to use this surgical s um And to be honest, for me, it's, it's never really worked. Um So you can give it a shot if it works for you. It does, if it doesn't, you can try something else, but essentially people run through the different causes of the different categories. So, vascular causes infective causes, traumatic causes autoimmune. Um And then come up with differentials with each um for, for each of them. Uh For me, I II can just never remember the acronym um or sort of link the different conditions to the topic that's in the acronym. So I normally tend to think of, if I hear a presenting complaint, I'll think of the big things that cause it. So for instance, for chest pain, a heart attack, pneumothorax, a pe uh and then I'll work on to the less critical and the less important things that cause it. So for instance, like costochondritis can cause chest pain, um A panic attack can cause a chest pain. So they still have medical conditions, but they are not as, as urgent as like an M I, for example. Um OK. So what would be covering today? I'll go through myocardial infarction, pericarditis, aortic dissection and anxiety causing chest pain as well. And then maybe you'll go through pneumothorax, pulmonary embolism Bohs and we'll touch on all sort of causes that we haven't covered today. So just to start off with the B eight. OK. So a 62 year old man, uh he presented with chest pain that started 30 minutes ago when he was watching TV. It is described as heavy and crushing it radiates to the left arm and jaw. He feels nauseous and he's sweating. He has a history of hypertension and hypercholesterolemia. Uh, his abs are normal. He's slightly hypotensive. Uh, he's also got some ST elevation in leads 23 and aVF and, yeah. Fantastic. So that's, that's a, a really typical M I um, all of the S PA S I'm gonna go through are gonna be quite, quite easy. The reason why I've done it is I, I've included every single sort of characteristic feature of the M I just because I, in the, in the, in the A KT, you won't get all of these features, but you need to try and remember all of them because you might have a list of differentials, having one symptom might help you rule in or rule out one of the differentials and that's the way you're gonna have to work through them. Um So, yeah, really books on an M I, the chest pain is crushing it radiates to his left arm and jaw. He feels nauseous. He's also got high cholesterol, which is a risk factor and then he's got the ST elevation and leads 23 and aVF. So I'm, I'm gonna go through this quite quickly just because I'm assuming everyone has a rough idea of, of what causes an M I. Um So essentially it's caused by a blockage in the artery that supplies the myocardium. Um, and that, that tends to lead to necrosis of the heart muscle and it's normally due to like a build up of an atherosclerotic plaque and that eventually ruptures which causes a blockage. Now, in terms of uh stem and ends sty. So there's ST elevated myo infarction and non ST elevated myocardial infarction. So, Temi is cau caused by a complete blockage in the artery where so no blood can get through. That causes a more severe heart attack. And it has that characteristic ST elevation on an an ecg uh ente is normal caused by a partial occlusion. So, it's a little less serious. Again, it still is a critical condition. Uh It tends to show variable uh E CG changes which will touch on in a second. And then we also have angina as well. So a angina is caused by. So, yeah, the stable angina, unstable angina. So in stable angina, your patient may have um chest pain that comes on when he's exercising or walking upstairs uh unless relieved by rest. And it, that's normally caused by sort of reversible myocardial ischemia. So it's where when they're exercising, the heart needs more, more oxygen. And if there is some slight narrowing in the arteries, the heart's not getting enough oxygen and that's when it starts to become a little bit ischemic, but that gets relieved by rest and, and, and that gets better. So unstable, angina is a more severe form and that also counts as an acute coronary syndrome. So essentially when, when the blockage gets so severe that they're getting ischemic at rest, that causes unstable angina. So in that kind of kind of angina, you don't get any relief when you rest or, or use your GTN spray. So in terms of how to differentiate all these, it's normally done by the eu changes and the troponin levels as well, and we'll go through that in a second. So in terms of risk factors, um if you're counseling the patient, it's always good to touch on risk factors, they normally fall into two causes. So you have non modifiable, that's stuff like your age, your family history, your gender, um then you have modifiable. So in the case of heart attack, there is smoking, high BP, diabetes, high cholesterol, obesity and sort of lack of exercise. Ok. So it's a bit of a cheeky question this, but I just wanna see if everyone can sort of get where the blockage is in this, in this heart attack. By the way, I want the right kind of heart attack and I also want the right artery that causes it as well because some of them are mismatched even if you're not 100% sure, just, just throw in a guess in a couple of seconds. Ok. Fantastic. So this is uh anterior stemi and it's a blockage in the left anterior descending artery. Um So the reason why is you can see the ST elevation in leads V two V three and V four. and that's characteristic of anterior sting and in anterior sting, the L ad supplies the sort of anterior different portion of the heart. Um We're not gonna go through the sort of E CG leads uh different heart territories and blood supply. The reason why is because we've done a previous talk on that before. Um So in that talk, we went through sort of a physiology of the heart, electrical conduction, uh EC GS from, from basics basically. So if you are interested in that, it's on the middle platform. Um ok, so in terms of the presentation of a heart attack, it as I mentioned before in that stem, uh it's left-sided pain. It normally radiates to the jaw. The left arm is described as heavy or crushing. The patient might also get short of breath, might feel nauseous, might feel sweaty or clammy. Um The thing to bear in mind is heart attacks don't always present with uh pain, especially in people that have diabetes or are elderly. They can have what's called a silent uh myocardial infarction. So in that kind of m I, they might feel some like heartburn kind of pain, they might feel no pain at all. So just because someone's not got pain, it doesn't rule out a heart attack. So just bear that in mind. Normally, observations are normal in people that have had a heart attack, uh unless they're in like heart block or they per arrest in which case, their BP might be low. Um So the most important thing to do is a ecg and a troponin level in Temi, you'd find ST elevation that's in the name nstemi. You'd normally find ST depression or T wave inversion and unstable Angina. You normally find a normal ecg, you might get some T wave inversion because tt wave inversion normally indicates some kind of ischemia in, in unstable Angina. You do have some ischemia. So you might find a little bit of T wave inversion, but it's quite variable. In terms of troponin, you'd find a raised troponin in a stemi and ends Demi because the muscle breaks down and release that troponin. Uh in unstable angina, you have a normal troponin level. So that's how we differentiate the two. So in terms of management, you have the immediate management. So as soon as someone presents, you want to do your A two E, you wanna make sure they're stable. Uh You wanna do an E CG as well and then you wanna administer. So I normally think moan. So first off, if the patient is in severe pain, you wanna give them morphine to control that. If their SATS are less than 94% you wanna give them oxygen. But if they're above 94 you don't give any oxygen unless it's contraindicated, you'll give 300 mg of aspirin, you'd also give nitrates as well. Again, unless that's contraindicated. So if patients have a low BP, you don't give nitrates because that's that's a contraindication. Then if you're in a GP, make sure you remember to call an ambulance, you wanna get your patient down to the hospital straight away. And then the management from here depends on the type of heart attack it is. So we'll put you on that now. So essentially have guidelines for, for the different types of heart attacks and sort of what happen after they leave the hospital as well. The thing is these, these guidelines are quite complicated but it is worth going through. So they've, they've also got all these sort of flow charts as well to make things a little bit easier. Um What I've done is I've summarized what's written in the flow chart. So we'll touch on that. So the patient gets to the hospital, they're diagnosed with a stemi what's gonna happen is um if the patient is presented within 12 hours of having a heart attack and you can do PC. So PC is the stenting, you can do that within two hours, then send the patient for, for PCI. The thing is.