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I just clicked that we've gone live. So good evening, everyone. If you can hear us, can you pop a message in the chat? Yeah. Fabulous. We'll just give it another minute or so for any latecomers and they'll make a star. Ok. No, no. Ok. We'll make a start. Um, so thanks everyone for coming this evening. This is the first episode of our presenting complaint series from, uh, the Ed, um, subsection of mind the bleed. Um My name is Eloise. I'm the, uh, one of the co leads for the, um, em, part of my league. Um, I'm very grateful that everyone has signed up to come today. Um, I'm very excited to present our speaker this evening. Uh, he is Doctor Jack, uh, who is, uh, se six at the Royal London Hospital in Whitechapel. Uh, and this evening he's gonna be presenting, uh, a talk on, um, managing the initial presenting complaint of chest pain. Um I will be monitoring the chats. Um, and we've got a few polls coming through as well from Jack. So do, uh, participate in those, ask some questions. Um And we can either address questions as we go along or we can save them up and ask them at the end. Um So without further ado I'll hand over to Jack. Um and yeah, enjoy everyone. Thanks for coming. All right. Thank you. Thank you very much um for the, for the introduction. Yeah, my name's Jack A, I'm an ST six in emergency medicine at the Royal London in Whitechapel. Er, and I've got an M SE in resuscitation and emergency medicine from QM UL um And I'm very happy to be here and hopefully we have a good session. Um So the first question really is why, why have a lecture on, on chest pain? Um And it's, it's mostly because chest pain is really common, it's 5% of, of all e attendances. Um And actually, with the advent of er advanced nurses, seeing many more injuries and lots of patients going to urgent treatment centers, seeing GPS, actually, when you work in ed, seeing undifferentiated uh chest pain feels like a lot more than 5% of of your workload. Um And it's got a broad differential from, from fairly benign causes to those which are life threatening um and quickly life threatening, you know, within minutes to hours if missed, there's no one algorithm for, for chest pain. If you look online, you'll find attempts at making a very long complex algorithm to manage any patient that might come in with chest pain, but it's just not really feasible. So, actually a core part of, of working in is, is sort of robustly identifying and treating that minority that do have serious pathology um while avoiding unnecessary investigations and admission for, for the majority who, who won't have serious pathology. Um And this lecture is, is aimed at sort of F one F two JC FS HO level doctors either about to start an ED or already working in ed wanting to improve their skills. Um by the nature of how much time we've got and how broad the topic is, we can't do a deep dive into every pathology that might give you chest pain. Um, but, uh, hopefully we can do a sort of pragmatic approach of what do I actually do as a reg or what does an ED consultant do day in day out, um, when they're assessing these patients and a few tips and tricks. But please do ask questions as we go along. Um, and I will do my best to answer them. So, what's the role of the resident doctor in, um, assessing a patient with chest pain? So, really, I put it down into to five steps. The first is to take an appropriately detailed history, um, which is fairly obvious then to examine the patient form, a differential diagnosis, get the right investigations to rule out the life threatening. Um, and then make a diagnosis or not, which we'll come on to. Um, and really the change in thinking as you move sort of into independent practice. And Ed is, is away from the sort of med student approach of just getting all the questions in the history and the examination. Um and actually trying to build a pretest probability to say what are the potential diagnoses, but more importantly, what are the emergencies which I have to rule out and how can I confidently rule them out so that I can sleep comfortably at night knowing that, you know, I haven't sent home someone that has had an M I and he's gonna come back and rest. Er, and that process takes a lot of time to, to perfect and definitely I haven't perfected it but it's getting, getting easier as, as time goes on, um, you can look up a table or a big chart of differential of chest pain, it can be extremely detailed. Um, and in a way not that helpful to, um, to try and learn, sorry, I've just lost my camera there. Um, and extremely broad and, and obviously we can't cover every cause of chest pain. Uh, but what you need to know is, um, those which are life threatening causes, which can't be missed. And I've just put this table that I put together of diagnoses that I commonly would think of. Er, and if you look at the left hand side, that column there, of life threatening causes, you need to be thinking about it in, in just about every patient and will be uh going through all of them in the lecture today. And even if you don't end up having to um, specifically investigate, to rule them out, you want to make sure they've crossed your mind in every patient that you're seeing with chest pain. And this differs really from, from specialty medicine where as they see patients in clinics or um on the wards, they might build up an increasingly complex layers of investigation until they finally get the right diagnosis here where building up increasingly complex investigations, but it's to rule out these dangerous emergencies. So if they can be ruled out with um our clinical judgment or with a scoring system, then we can leave it at that. If they need blood tests, ECG um CT S and more complex investigations, then we'll do those. But the ultimate aim is to be ruling out those emergencies that are life threatening. Um And if we get the right diagnosis along the way, then that's obviously a benefit, but it's not always possible. And Ed and just sort of shown in a, in a picture there. Obviously, we've got 65 or six life threatening diagnoses which all of us will know and want to be sure that we've ruled out some of those you're not going to miss and no one would miss because by nature of the pathology, the patient is always going to be really unwell, but we know that some of them can be quite subtle and at the time you're seeing the patient, they might not be acutely unwell, such as um with ap uh even a dissection or an acute M I. And so those are the ones that we're particularly going to focus on today. So I said it's five steps. So history is our, is our first step. I'm not gonna overly discuss unstable patients because actually they uh in some ways don't cause such a diagno diagnostic dilemma that the pretest probability is really high for serious pathology. We know something is wrong if they're hypotensive in respiratory distress and then unlikely to be missed. So obviously, they should go into recess, they should get a cardiac monitor on. We should be looking at sort of ABC examination and supplemental oxygen. I'm a big advocate for point of care ultrasound, although we won't get to talk about it much this evening. Um And then you want to assess for those life threatening causes the vast majority of patients and we're gonna focus on today is the patients who are stable. Um That may take a bit more work to work out if they're genuinely having an emergency cause of their chest pain and how we can do that. I don't want to patronize you by teaching you how to take a history cos everyone knows how. Um But I want to emphasize the point that a detailed history in chest pain is genuinely, really useful and genuinely can lead us to getting the right diagnosis and knowing what tests we need to do. So I'll go through a few points on the history and I use the Socrates, um mnemonic just because it's helpful to lay it out like that. But I wouldn't really expect people to document it in that order. So sight is obviously essential. And the bigger thing with sight is not so much where they're pointing, but it's whether or not can a patient point with one finger specifically to where that pain's coming from.