Chest Pain in General Practice Case Discussions Tom Gamble 18.11.09

Chest Pain: 5-8% of emergency department presentations Still a common presentation in general practice – 1.5% of GP consultations are with new chest pain What are the life threatening causes of chest pain? MI; PE; dissecting aortic aneurysm; (pericarditis); pneumothorax; (abdominal). What are the most common causes in GP? Dyspepsia; musculoskeletal; anxiety/panic; pneumonia; cardiac Important features: Hx/examination.

Case 1 68 year old man with no previous history of cardiovascular disease. Tightness in chest for several months, comes and goes Mainly comes on when taking dog for walk on hills. Father had stroke in 60s. A bit short of breath with it, sometimes radiates to neck. Always goes if stops walking Examination/Investigation/Management?

Case 2 40 year old woman with burning pain in chest, sometimes feels nauseus with it. Worried as mother recently had MI Sometimes gets when not eaten for a while, sometimes at night. Not exercise related, lasts an hour or so. Further Hx/Examination/Investigation/Management

Case 3 76 year old woman with Hx of MI 7 in 2003. 2 days ago had episode of central chest pain, sweating and breathlessness, but now feels fine, thinks it may be anxiety over grandson’s recent illness On direct questioning admits angina has returned and been a little worse last few months Examination/Investigation/management?

Case 4 33 year old woman has chest pain and tightness, especially when she takes a deep breath. On COCP, flew to Spain 3 weeks ago, had bad cough while there, seemed to start around then. Thinks mother had a DVT after a knee operation. Examination/investigation/management?

Case 5 A 45 year old businessman has had several episodes of chest pain in the last few months. They last a few minutes, he feels breathless and ‘like he’s going to die’, then they settle down. There’s no obvious cause No previous cardiac history, BP has always been fine, goes to gym regularly. Ex-smoker, recent cholesterol reading of 6.5. Further examination /investigation /management?

Case 6 – Your first patient in general practice: 65 year old hypertensive man with COPD. Presents with recent increase in breathlessness on exertion with associated chest pain. He has a productive cough, occasionally with some blood. He can’t really describe his pain very well, it’s there all the time but worse when exercising/ breathing harder, and better when leaning forward. Indigestion tablets helped a bit, as did a friend’s GTN spray. He’s noticed his ankles are a bit more swollen recently, the right slightly more than the left. He mentions that the pain radiates to his back. During the consultation it becomes more severe. You notice his systolic blood pressure on the left arm is 30mmHg lower than the right. A minute later he collapses unconscious. What is the likely diagnosis?