 All right guys, what is going on? Luxury of an empty journey helping you succeed on your medical journey with less stress. Today I have another case for you and we are going to be talking about chest pain. Now chest pain is something that you've probably seen especially if you're a med student or you're about to start residency. But really the goal of this video guys in my case is to give you basic questions that your attending may ask you, the nurse may ask you. I'm gonna treat you like the doctor on the case, taking care of this patient. And I want you to see if you can answer some of the most basic questions without having a multiple choice in front of you and come up with more than just like the most simplest answers. So let me give you the questions ahead of time because I want you to see positive video and see if you can answer this. So what's the differential diagnosis for chest pain? Can you come up with, let's just say anywhere from six to seven? If you're attending ask you now, what would you say? Next let's say what would be your workup? What would be anywhere from four to five things you would order for this patient that comes in with chest pain? I'm gonna give you the case in the second. And then next let's talk about other things. So let's say we are talking about ACS, Acute Coronary Syndrome. What are the four types of ACS can you tell me? Next let's talk about, do you know what a timmy score is? Can you pause the video and explain to me or teach to me what a timmy score is? And then finally let's talk about things like conservative management. If you're gonna be the doctor and you are gonna treat your patient with conservative management, what would that be? What would you treat them with? What would not be options? What would be options? So see if you need to go ahead and pause the video and see if you can come up with answers to these questions. And if not, we're gonna go through them each one by one. But this is a good kind of tool to help you identify what you know, what you don't know. Maybe you only have like four differential diagnoses. Maybe you don't really know what to do after the first like simplistic things on the workup and so on. So let me give you the case and then we'll get to each of the questions. So here's your case. You have a 75 year old comes to your hospital ED and his son brings him because he's just confused. And yeah, the son's not really sure what's going on. But he does mention that his dad did have some chest pain early in the day, but now he's just acting weird. So let's ask some basic questions. What are some of the questions you would wanna know regarding his chest pain? Because that's what this video is about. So chest pain, things that we ask our location. So we're gonna say that his pain is sub-sternal, which is already gonna make your ears perk up. So right in the middle of his chest, we're gonna ask radiation, does it go anywhere? And he's gonna say, yep, it goes, or dad mentioned that it went to his left shoulder. It moves from his middle of its chest to his left shoulder. We're gonna say time, how long does it last? If it's been going on for three weeks and we're not really concerned about maybe something like a heart attack, but we're gonna say it happens a couple of, the pain has been going on and off for 20 minutes and now he's acting really weird. We're not really sure what's going on. You may ask about other symptoms. And he says, yeah, my dad was feeling nauseous earlier today according to my mom, but he looks even worse right now. So let's just say those are some of our basic symptoms. I really wanna get into these questions. So you as a doctor, what are some of the things that you would want to kind of look at? Let's just say we get some basic vitals on him, okay? That's gonna be part of your workup. So answer number two is going to be, get some vitals for sure. He's in your ED and oh boy, this is his blood pressure, guys. 90 to over 45, which is super low. He's hypotensive. His heart rate is right at 100. So he's right at being tachycardic. Doesn't have a fever. And we're gonna say as 02 sets, how he's breathing, he's doing okay for now 97%. So those are his vitals, you know, and we look at him, we do a physical. So that's gonna be another part of our workup. And things that we really notice is that he has lower extremity edema. So he has some swelling in his legs. It's a fancy way of saying that. And he has some crackles in his lungs. So it sounds like he has some fluid. We ask his son about his past medical history and the son's not too familiar. He doesn't live in the same state as him. He just came back to visit or on a work trip and his dad happened to be confused. So all right, doctor, let's answer question number one. So given this history, what is your differential diagnosis? So let's see if we can come up with a few. So pause the video if you haven't done so already and come up with one. If not, let's get into it. So differential diagnosis, we're gonna look at ACS. Obviously as we're talking about in this video, but I want to help you kind of come up with a bigger one. So ACS, you know, this is a fancy word for heart attacks, test pains that would come in. This is the first thing you wanna think about. But what are other things that you would want to look at? So other, let's look at other cardiac causes. So something else that you could have is an aortic dissection. In that region, which is also known to have chest pain. Other things that you can have that are not as severe, things like acid reflux or GERD for pneumonia is known to also cause chest pain. You could have a pneumothorax, which is just air filled up in the lung cavities, kind of pushing on the lungs, making it really hard to breathe. Let's do one more. So you could have something as simple as costocondritis. And essentially, this is an MSK problem, a musculoskeletal problem, where you just have some inflammation of your rib muscles, rib cartilages. So it feels like chest pain, but it's different on the outside. So here's your differential. You may have came up with a lot more than I did. So if you did, awesome. But six is usually a good number for now. So now what we wanna do is we obviously need to look at a workup and we've done a little bit. So let's see what we can take out from our differential. So things like costocondritis, this person has really bad radiating chest pain. And we're gonna say that when we push on the area of his chest, the patient doesn't really feel more in pain. So costocondritis is usually not on our list. He doesn't really have a fever, which probably takes out pneumonia, but we could do an X-ray just to confirm. Certain things like a pneumothorax, you may be able to pick up on your physical exam, but you may also wanna do an X-ray. So you may wanna do an X-ray on this patient just in case you're worried about something else. And things like an aortic dissection, same thing you can do like a CT scan. And GERD, we're gonna take GERD out, it's probably just not as severe. So these are the things we're considering, but obviously we're gonna be talking about ACS today. So we have our differential diagnosis and now we're gonna talk about workup. So I'm gonna erase this and we're gonna get into our next question, which is what kind of workup would we do for this patient, for a patient that we're just concerned about having ACS? So an ACS workup. So we've done a physical exam, we've done vitals, what's something else that you definitely wanna order in this patient? If you're yelling through the video, bro, you better get an EKG, definitely. EKGs are huge. And let me actually give you the EKG to this patient. See, I think it's this one. There it is, that's my EKG for this patient. So I'm not gonna spend forever on EKG because some of you guys may be familiar with them, so otherwise some of you guys may not be, but I am just going to point out what you should be able to identify after looking at several EKGs. That, well, let me change the color. Maybe I can change the color, there we go. And let's make that a little smaller, it'll be easier to see. So this right here, that right there and this right here. So that is not normal. This is what we call ST elevation. So fancy word, essentially. This is the spike that most of us know is the QRS complex. And after that, we have the S to the T wave. And if this is going up, then that's an ST elevation. So QRS, and here's your T wave and there is an elevation in that part, elevation here and elevation here. This just shows potential and likely damage to the heart. Where, this is probably what a normal one would look like, although it has a little bit there too, but these are severe. Now the reason that I circled those specific ones, if you're unfamiliar with the EKGs is that these locations, two, three and AVF, are basically pointing to the inferior portions of the heart. So if you have elevations here, that also shows you that damage to the heart are located in that inferior region. So you can already tell by looking at EKG what part of the heart is damaged or is at risk of being damaged. So this person comes in with what we call inferior infarct. So that's where we are right now. So I already gave you that patient's EKG. What are other things that you would want to order? We want to order triponins. So triponins are cardiac enzymes which are released if you have muscle damage, which the heart is basically a big muscle. And so an elevation. So this patient I'm going to tell you is 2.5 and a normal is like less than 0.01. So he clearly has an elevated triponin. Now other things that you would want to check on this patient are things like just a CMP. You would want to get things like magnesium, check their potassium, because electrolytes can cause chest pain and arrhythmias and they can also impact your workup and how you take care of this patient. So you want to make sure of these things as well. So these are basic things. I mean, obviously you're going to get things like an X-ray, you may get an echo in these patients, but these are going to be some of your basic workups. So now let's talk about number three. What is going to be your essential differentials? What are the types of ACS? So ACS again is acute coronary syndrome. And basically it comes down to four different types. So hopefully you have already told me the different types, but you have stable angina. You have unstable angina. You have an N-stemi, and then you have a stemi, okay. So what are the differences between these? Here's another question, pause the video if you need to. And instead of going to write it out, I found a good picture of you guys. I really wanted to show this. So here is a good difference and I'll link this down below, but here are the main differentials between them. So between stable angina, I can actually draw on this so it's perfect. Between stable angina and anginora here, the difference is between demand and supply. Here basically act like stable angina is if you are working out and if your vessels just don't have enough flow to allow blood to go through. So you feel the chest pain because you know, you need the extra blood, but your body and your vessels are not open enough to give you that blood. So you feel it when you need it. So you may be exercising like, have chest pain, that's stable angina. So unstable angina is supply. So over time you're having clots. So even if you're not exerting yourself, even if you're just sitting around, blood is having issues getting from one into another because of plaque buildup, because of clot, a thrombus start in the form. So you start to have minor chest pain by even just by sitting around. So that's unstable angina. But nothing's changes on their EKGs, okay? They're likely just going to be normal over time. And because we're not really damaging any of the heart muscles, this is the heart muscle, then your troponins or the cardiac enzymes are going to be normal. Now if we keep working our way this way, you have an end stemmy, which basically says that you are going to now have plaque buildup and clot form to where blood is definitely going to be minimized more so than the end stable angina. And this is where you're really going to start showing signs on the EKG of damage. So you're going to have what we call SD depression, which is, again, here's your QRS, and the dip between that and your T-wave is going to be kind of decreased right there. Or you'll have inverted T-waves. So don't worry too much about the T-waves. Again, they're just of a wave that's supposed to go normal. So here's a QRS that goes in this direction, and the T-wave should go in the same direction as the QRS. If it flips, that's called inverted. Another sign of ischemia or damage to the heart. Now, one more step. This is a big kahuna, the thing that we often consider a heart attack where you have a full blockage and blood just can't go to the other end. And you have full damage. You're starting to really infarct and permanent damage to your heart. At these points, because you have heart muscles that are actually at risk, anterior and working your way outwards, you're going to actually increase elevations of your triponents. So those are the different types of ACS. So stable angina, again, happens with exertion. And this is demand. And then everything here on out is a supply issue. You have blockage, you're just not able to get it there. And then remember the last thing that we look at are things like our EKGs and our triponents. So EKGs here is normal, is normal. You're not going to notice a difference. In an end stemming, you're going to have ST depression and ST elevation and a stemming. And then triponents also going to be negative here, negative here likely is going to be increased and definitely is going to be increased in an ST and a stemming. So hopefully that helps. Hopefully you guys got that. But this is basically an ACS and I'll link that picture that I shared with you. Now let's get into number four. So based off of really quickly, based off of the EKG that I showed you for our patient, which is this one, what kind of ACS does our patient have? So if you are saying that he has a stemming, which is an ST elevation, then you are right. So he is in this very last category. And the reason this really matters guys is how you treat these, basically how you treat this category versus this category is different. And so that's where we get into our Timmy score. So maybe you already know what a Timmy score is, but I'm not going to get too far into details of what a Timmy score, what all of the components are, because luckily we have calculators now in medicine, we just have to type things in. But a Timmy score basically helps you identify, does this person go to the cath lab, which is a procedure that you're going to be using to open up the vessel that's blocked or are they going to be getting METs and conservatively managed. And the essential to the way it is, is a Timmy score involves a lot of things, their age, how does a EKG look, do the haptaraponins, and you put it in the calculator and it's going to give you a number. Basically if the number is greater than two, they go to the cath lab. And if it's less than or equal to two, then they get METs, okay. So it's basically a severity case. These patients are a huge risk for dying. And so you want to make sure you do everything in your power within the first 12 hours. That's the best time to save their heart. It was within the first 12 hours, you take them to the cath lab, or send them to a hospital that has a cath lab. And then if not, you go and do METs. So let's talk about our METs, okay. So now it's kind of going into our conservative management. What METs would you give these patients? So pause the video if you haven't answered it, but if you know this acronym, you know the METs. And I'm going to give you kind of something to consider because although acronyms are helpful, they're not always utilized in every single patient. So monobash is basically what we use to help distinguish what we give these patients. So the M stands for morphine, which helps with the pain. The O stands for oxygen. So if your patient is less than 90% on O2, then you give them some oxygen. Our patient was at 97, so they may not necessarily need this. N stands for nitroglycerin, which is something that will help dilate your blood vessels and essentially relieve some pain. So a lot of patients improve with giving some nitroglycerin. And do you know how much you can give? So you can essentially give them nitroglycerin, like one dose, up to three times in 15 minutes. Okay, so nitroglycerin actually acts really fast. And so you can give them up to three doses within 15 minutes. And as long as their chest pain is relieved. Don't give them obviously more than 15 minutes and we'll come back to nitro in a second. A stands for anti-platelets. So you don't want them to continue to form clots and thrombies in their blood vessels. So you give them things like aspirin and you give them things like platyx. So these are two medications that you almost always use in patients. Obviously you keep in mind there are other paci-medical histories, but you give this to your patient to avoid worsening their heart attack. B stands for a beta blocker. So basically this is, if you're not familiar, this is essentially a medication that will help the heart work a little less intensely and there's a lot of demand already put on it. So it's gonna calm down. A is going to stand for an ACE inhibitor, which is shown to improve mortality in a lot of these patients. And so you can give that. S stands for a statin. So usually your cholesterol buildup is the reason you have the plaque. And so you give this to the patient, essentially for a long term. And then H finally is heparin. So heparin is going to avoid forming up bigger clots and you can give this to the patient to essentially avoid making the heart attack even worse. So these are the things that you would get them, okay? So let's get back to our patient though. Monobash is something that you guys learn. You probably remember. And if not, you are reintroduced to it. But what would you not give our patient? Remember, this is their EKG. So there's a little bit of an advanced topic for med students is something that you probably see on your board exams. So if you're screaming to me that this person should not get their nitroglycerin, you are absolutely right. Because this patient has what we call a right-sided infarct. So when you have an inferior infarct like this, remember these are the leads that are pointing towards the bottom of the heart. This is likely going to be involved in the right ventricle. Now the best way that I like to teach this is imagine you have a bucket, okay? And just like our heart, this bucket has four chambers. So I'm going to draw two buckets to give you the example of why we don't give nitroglycerin. And then we'll have some pipes going in and some pipes going out. So what nitroglycerin does is in a normal case, you have some blood going in and it's going to flow and it's going to go to your right ventricle, left atrium and eventually back into your left ventricle. Now nitroglycerin increases essentially your diameter of your vessels. So you have the same amount of fluid come in, but not as much pressure, okay? So instead of maybe this much of the chamber being filled in, you essentially have less come in each time. So the flow, the forward flow is not as strong. This is called your preload. This is like a fancy word for how much fluid dynamics is coming forward. And the better your preload, the less your heart has to work because the flow is going to essentially push itself forward and make your heart easier to squeeze it. Now, if your preload is decreased because your diameter of your vessel is larger, your heart is not going to be able to get enough blood to itself as well as the rest of the body. And remember, where in a heart attack situation, the body's already struggling to get blood. So if you're, let me go ahead and erase this and try this again. If your body has a right side and infarct. So this is the right side. If this side is damaged for whatever reason, because that's where our heart attack is happening. Then decreasing our preload and giving less blood is going to make it even harder for this blood to pump in this direction and then out of the body. So you don't want to give nitroglycerin because you want to keep this pressure of kind of forward flow as much as it possibly can. Nitroglycerin will lower this and so you don't want to give this to the patient. So you can give something like morphine or something else for the test pain for this patient, but definitely not give the nitroglycerin. Essentially, now let's quickly just kind of wrap up our case and talk about one more advanced topic is why is our patient confused? You know, remember I told you this was like a 75 year old man comes in confused and his blood pressure is super low. Remember his blood pressure was 90 over 45 plus he's confused. So the reason this happened, oops, let's take that away. The reason this happened is I'm gonna clear up some of this is his heart is what we call in a situation of cardiogenic shock, which is just a fancy way of saying his heart's not working right and the pump, which is our heart is not able to get blood to the rest of the body. So again, here is our four chambers and we have damage right here inferior part of our heart and it's just struggling. You know, normally a situation will make it in green is it's gonna move and it's gonna nicely kind of flow out but our heart is struggling, it's kind of wimping through. It's not really, it's just not doing the job just quite right. So because our patient is not getting the same amount of blood compared to an ideal situation his brain is getting less flow and his heart is pumping less blood. So he's becoming hypotensive because he just doesn't have enough pressure in his vessels even after his body is trying to increase the pressure. It's not and he's confused because his brain is just not getting enough flow. So for this patient, as I mentioned you wouldn't give them nitroglycerin because you don't want to decrease even the forward flow even more so and you wanna avoid something like a beta blocker right now because his heart is already working slow. You don't want it to slow it down even more. So these are kind of advanced topics that you don't really always learn about and a patient with a heart attack but now given the scenario, you have a patient with a chest pain who clearly has really severe damage where the heart's not pumping forward and now has some collateral damage going on with his brain and remember he had crackles in his lungs and this is gonna be the last point because his blood's not flowing forward because his heart's not squeezing, the pump's not squeezing, then that blood is starting to back up. So it's starting to back up in his lungs, it's starting to back up in his legs and so this is just a picture of cardiogenic shock. So what would you do for this patient? One, you would stabilize him. He would obviously go to the cath lab because he has a really bad stemmy and hopefully that helps. You would give him some fluids as long as he can tolerate it to help this forward flow and then you can give him medications like dobutamine which essentially help the heart squeeze a little bit better. So these are kind of advanced things you would do. Again, we've kind of strayed away from the heart attack and ACS but again, it's not as cut and dry and simple as sometimes our medical cases on our board exams make it out to be. Your patients are going to have a lot of steps. So this is going to be a relatively simple case with a lot of nuances going on. So hopefully you guys enjoyed it. Now if you did enjoy it, first of all, make sure you give this video a like and kind of let me know if you enjoyed it. So definitely comment down below with what you learned. Maybe I made some mistakes. I apologize for that to help me point that out so other people can learn from my mistakes. I'm not beyond making mistakes. I've probably made one or two at least. So comment down below and definitely subscribe to the channel helping me kind of grow this community. I love teaching you guys as long as you guys are ready to take my lessons. If not, you can click on the video at any time. But yeah, join the community, subscribe to the video, tell me what you guys want in the future. Thank you guys so much for making it to the end. Hopefully you guys found this helpful but I will talk to you guys soon. Take care.