mlawizard

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Instructions

You are a foundation year doctor in A&E. A patient presents with severe abdominal and back 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 Abdominal Aortic Aneurysm.
Explain less likely and red flag differential diagnoses could be acute mesenteric ischemia, acute myocardial infarction, aortic dissection.
Suggest bedside investigations of vital signs including bilateral blood pressures, abdominal examination, peripheral pulses.
Suggest laboratory investigations of FBC, U&Es, clotting, group and save, troponin.
Suggest imaging of immediate CT angiogram, bedside ultrasound if immediately available and patient stable.
Suggest interventions of immediate vascular surgery referral, hospital admission, IV access (two large-bore cannulas), fluid resuscitation, blood products on standby, pain control, optimization of blood pressure.

Internally Approved

Surname/Nom (1)

Mitchell

Given names/Prenoms (2)

Robert

Date of birth/Date de naissance (4)

26 APR 1952 (71)

Sex/Sexe (5)

PRESENTING COMPLAINT

You developed sudden severe pain in your abdomen and back about 2 hours ago. The pain is constant, feels like something is ripping inside, and is much worse than any pain you've had before. You also feel light-headed and sweaty.

IDEAS, CONCERNS AND EXPECTATIONS

You're worried this might be serious as you've never had pain this bad before. Your brother died after having something similar.

SYSTEMS REVIEW

Severe central abdominal and back pain. Feeling faint and clammy. No vomiting but feeling nauseated. No change in bowel habits. No urinary symptoms.

PAST MEDICAL HISTORY

High blood pressure for 15 years. Heart attack 5 years ago. Chronic smoker's cough.

DRUG HISTORY

Ramipril 10mg once daily, Aspirin 75mg once daily, Atorvastatin 40mg once daily, Bisoprolol 5mg once daily. No allergies.

FAMILY HISTORY

Brother died suddenly aged 65. Father died of heart attack aged 60.

SOCIAL HISTORY

Retired builder. Lives with wife. Smokes 20 cigarettes daily for 50 years. Drinks 21 units/week.