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?