mlawizard

Preparing your case...

0% Complete

Instructions

You are a foundation year doctor in A&E. A patient presents with increasing episodes of chest pain.

1. Take a focused history from the patient.

2. Explain your differential diagnoses and management plan to the examiner.

Checklist

History

Introduction

Adheres to appropriate infection control.
Introduces themselves by name and role.
Confirms identity of patient.
Explains history taking process and gains consent.

Presenting Complaint

"What's brought you in today?"
Asks about specific location of chest pain.
Asks about how and when chest pain started.
"How would you describe the pain?"
"Does the pain spread anywhere else?"
"Do you have any other symptoms with the pain?"
"Has the pain changed since it began?"
"Does anything make the pain worse?"
"Does anything make the pain better?"
"Have you taken anything for the pain?"
"On a scale of 0-10, if 0 is no pain and 10 is the worst pain you've ever experienced, how severe is your chest pain?"
"Has this ever happened before?"

Ideas, concerns and expectations

"Is there anything you think could be causing this?"
"Do you have any concerns about your symptoms?"
"What are you hoping I can do for you today?"

Summarise & Signpost

Summarises the presenting complaint.
Asks if they have missed anything.
States what they plan to discuss next.

Systems Review

Asks about fatigue, fever, weight loss or gain, night sweats and malaise.
Asks about cough.
Asks if chest pain is worse when breathing in.
Asks about nausea and vomiting.
Asks about bowel movements.
Asks about urine output.
Asks about visual changes.
Asks about headache.
Asks about chest wall musculoskeletal pain.
Asks about trauma.
Asks about rashes.

Past Medical History

Asks about diagnosed medical conditions.
Asks if patient is currently undergoing investigations.
Asks about previous surgery or procedures.
Asks if patient has any allergies.

Drug History

Asks about prescribed medications.
Asks about over-the-counter medications.
Asks about supplements and home-remedies.

Family History

Asks about family history of cardiovascular disease.
Asks about family history of any other medical conditions.

Social History

Asks about home life and pets.
Asks about personal support network.
Asks about smoking and alcohol history.
Asks about recreational drug use.
Asks about occupation.
Asks about mobility.
Asks about diet and exercise.

Closing

Summarises key points.
Asks if the patient has any questions or concerns.
Thanks patient for their time and explains next steps.
Adheres to appropriate infection control.

Management

Explain most likely differential diagnosis is Unstable Angina.
Explain less likely and red flag differential diagnoses could be NSTEMI, prinzmetal's angina, microvascular angina.
Suggest bedside investigations of vital signs, 12-lead ECG, capillary blood glucose.
Suggest laboratory investigations of serial troponins, FBC, U&Es, lipid profile.
Suggest imaging of chest X-ray, consider coronary angiogram.
Suggest interventions of hospital admission, oxygen if sats <94%, IV access, increase anti-anginal medication (consider IV nitrates if severe symptoms), loading dose ticagrelor 180mg if not contraindicated, fondaparinux 2.5mg SC, urgent cardiology referral, risk stratification using GRACE score.

Internally Approved

Surname/Nom (1)

Reynolds

Given names/Prenoms (2)

Patricia

Date of birth/Date de naissance (4)

10 DEC 1962 (62)

Sex/Sexe (5)

PRESENTING COMPLAINT

Tonight you had chest pain while watching TV. The pain is central and radiates to your left shoulder. The pain feels like tightness and squeezing of the chest

IDEAS, CONCERNS AND EXPECTATIONS

You're worried because your angina seems to be getting worse and your GTN spray isn't working as well as it used to. You want to know if your heart condition is deteriorating.

SYSTEMS REVIEW

Central chest tightness, radiating to left shoulder. Now occurs after walking just a few steps or at rest. Each episode lasts 5-10 minutes. GTN spray only partially relieves symptoms now. No palpitations. Mild breathlessness with pain.

PAST MEDICAL HISTORY

Angina diagnosed 1 year ago. Chest pain now occurs after walking just a few steps. Each episode lasts 5-10 minutes. No palpitations. Mild breathlessness with pain. Hypertension. Osteoarthritis of knees.

DRUG HISTORY

GTN spray PRN, Bisoprolol 5mg once daily, Ramipril 5mg once daily, Aspirin 75mg once daily, Atorvastatin 40mg once daily. No known allergies.

FAMILY HISTORY

Sister had heart attack age 65. Mother had angina.

SOCIAL HISTORY

Retired school teacher. Lives with husband. Ex-smoker (quit 5 years ago, 30 pack-years). Minimal alcohol. Limited exercise due to knee pain.