Mr Carsington Returns! Chest Pain in Primary Care Justin Walker September 2009

Aims  To consider the differential diagnosis of a patient presenting with chest pain  Appropriate initial management  Referral Options

Mr Carsington  A 60 year old owner of a fish and chip shop with diabetes who smokes and has a history of high blood pressure says that he made an appointment to see you this morning because he’s had pain in his chest. He didn’t want the bother of an ambulance or to hang about in A&E.  What questions do you ask?

Pain  Location  Type  Severity  Radiation  Exacerbating/relieving factors  Duration  Associated symptoms  Previous episodes

Cardiac Risk Factors  Male  Diabetes  Smoking  Hypertension  Age  Hypercholesterolaemia  Hyperlipidaemia  Prior CVA.

Differential Diagnoses  LIFE THREATENING  Acute myocardial infarction  Angina/Acute coronary syndrome  Pulmonary Embolism  Aortic dissection  Tension pneumothorax  Oesophageal rupture

Differential Diagnoses II  Pneumonia  Chest wall pain – muscular, rib fractures, bony metastases, costochondritis  GORD  Pleurisy  Empyema  Pericarditis

Differential Diagnoses III  Oesophageal spasm  Herpes Zoster  Cervical spondylosis  Intra-abdominal – cholecystitis, peptic ulceration, pancreatitis  Sickle-cell crisis

Where to go?  A&E  Rapid Access Chest Pain Clinic  Cardiology outpatients

RACPC Referral Criteria and Exclusions  Refer suspected new onset angina (<4 week history of exertional chest pain or SOB  Exclusions: Uncontrolled HTN (Cardiology OPD) Uncontrolled HTN (Cardiology OPD) Palpatations as sole symptom (Cardiology OPD) Palpatations as sole symptom (Cardiology OPD) Male pts < 30 Male pts < 30 Female pts <40 Female pts <40 Clinical suspicion ACS – emergency referral Clinical suspicion ACS – emergency referral

Practical Issues  MONA?  Location of resus equipment in surgery?  Location of Oxygen?  Drugs in doctor’s bag?