Mr Carsington Returns!Mr Carsington Returns!

Chest Pain in Primary CareChest Pain in Primary Care

Justin WalkerJustin Walker

September 2009September 2009

Aims Aims

To consider the differential diagnosis of a To consider the differential diagnosis of a patient presenting with chest painpatient presenting with chest pain

Appropriate initial managementAppropriate initial management Referral OptionsReferral Options

Mr CarsingtonMr Carsington

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

What questions do you ask?What questions do you ask?

PainPain

Location Location TypeType SeveritySeverity RadiationRadiation Exacerbating/relieving factorsExacerbating/relieving factors DurationDuration Associated symptomsAssociated symptoms Previous episodesPrevious episodes

Cardiac Risk FactorsCardiac Risk Factors

MaleMale DiabetesDiabetes SmokingSmoking HypertensionHypertension AgeAge HypercholesterolaemiaHypercholesterolaemia HyperlipidaemiaHyperlipidaemia Prior CVA.Prior CVA.

Differential DiagnosesDifferential Diagnoses

LIFE THREATENINGLIFE THREATENING Acute myocardial infarctionAcute myocardial infarction Angina/Acute coronary syndromeAngina/Acute coronary syndrome Pulmonary EmbolismPulmonary Embolism Aortic dissectionAortic dissection Tension pneumothoraxTension pneumothorax Oesophageal ruptureOesophageal rupture

Differential Diagnoses IIDifferential Diagnoses II

PneumoniaPneumonia Chest wall pain – muscular, rib fractures, Chest wall pain – muscular, rib fractures,

bony metastases, costochondritisbony metastases, costochondritis GORDGORD PleurisyPleurisy EmpyemaEmpyema PericarditisPericarditis

Differential Diagnoses IIIDifferential Diagnoses III

Oesophageal spasmOesophageal spasm Herpes ZosterHerpes Zoster Cervical spondylosisCervical spondylosis Intra-abdominal – cholecystitis, peptic Intra-abdominal – cholecystitis, peptic

ulceration, pancreatitisulceration, pancreatitis Sickle-cell crisisSickle-cell crisis

Where to go?Where to go?

A&EA&E Rapid Access Chest Pain ClinicRapid Access Chest Pain Clinic Cardiology outpatientsCardiology outpatients

RACPC RACPC Referral Criteria and ExclusionsReferral Criteria and Exclusions

Refer suspected new onset angina (<4 week Refer suspected new onset angina (<4 week history of exertional chest pain or SOBhistory of exertional chest pain or SOB

Exclusions:Exclusions: Uncontrolled HTN (Cardiology OPD)Uncontrolled HTN (Cardiology OPD) Palpatations as sole symptom (Cardiology OPD)Palpatations as sole symptom (Cardiology OPD) Male pts < 30Male pts < 30 Female pts <40Female pts <40 Clinical suspicion ACS – emergency referralClinical suspicion ACS – emergency referral

Practical IssuesPractical Issues

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