SLIDE 1 ì
Chest Pain
StudyHub OSCE History Taking Session
SLIDE 2 Differentials for Chest Pain
How it works:
- 1. Someone opts to be patient. We will privately message
you the diagnosis, and some points to help you answer the questions asked. We haven’t told you everything, so use your knowledge to beef up the history. Don’t make it too hard!
- 2. There are then 3 opportunities to participate, or if you are
confident you can take them all on!
- Person 1: is the doctor/student, takes a short 5
minute history
- Person 2: Tell us what investigations they want to
run and why
- Person 3: Tell us what this patient has come in
with and how they would manage them
SLIDE 3
Vote for investigations anonymously
SLIDE 4
Mini History 1
ì 70 year old man presents to A&E with sudden onset
tearing chest pain radiating to the back, 10/10
ì Person 1: You are the FY1, take a short 5 minute
history
ì Person 2: Tell us what investigations you want to
run and why
ì Person 3: Tell us what this patient has come in with
and how you would manage this patient
SLIDE 5
Mini History 1
ì 70 year old man presents to A&E with sudden onset
tearing chest pain radiating to the back, 10/10
ì PMH – IHD, HTN, Diabetes ì BP 80/50 – asymmetrical ì HR 140 bpm ì Elevated D-Dimer, non-specific ST elevation globally
SLIDE 6 Mini History 1
ì
AORTIC DISSECTION
ì
Bedside: ECG – exclude cardiac pathology
ì
Bloods: FBC (Hb drop), U+E (pre-renal AKI due to hypoperfusion), troponin, group and save, cross match, clotting screen, lactate, d- dimer
ì
Imaging: CXR (widened mediastinum), CT angiogram
ì
Management: ABCDE approach, high flow oxygen, IV access, fluid resus (cautiously). Then depends on type. Type A = surgical, Type B uncomplicated = medical
ì
Long term: antihypertensive therapy and surveillance imaging
SLIDE 7
Mini History 2
ì 47 year old man presents to A&E with epigastric
pain radiating to his back following repeated episodes of severe vomiting.
ì Person 1: You are the FY1, take a short 5 minute
history
ì Person 2: Tell us what investigations you want to
run and why
ì Person 3: Tell us what this patient has come in with
and how you would manage this patient
SLIDE 8
Mini History 2
ì 47 year old man presents to A&E with epigastric
pain radiating to his back following repeated episodes of severe vomiting
ì Haematemesis, melena, dizziness and syncope ì FBC shows normocytic anaemia
SLIDE 9 Mini History 2
ì MALLORY-WEISS SYNDROME
ì
Longitudinal mucosal tears, usually at the gastro-oesophageal junction
ì
Bedside: Obs (HR,RR,BP… etc determine if stable), calculate Glasgow Blatchford score, monitor fluid status
ì
Bloods: FBC (anaemia), VBG (lactate), clotting, G+S, crossmatch, urea (if high suggests significant fluid loss)
ì
Imaging: erect CXR
ì
Management: ABCDE approach, IV access, fluid resus, endoscopy (diagnostic and therapeutic) +/- antibiotics and terelepressin
SLIDE 10
Mini History 3
ì 50 year old male presents to GP with sharp
epigastric pain that radiates retrosternally
ì Person 1: You are the GP, take a short 5 minute
history
ì Person 2: Tell us what investigations you want to
run and why
ì Person 3: Tell us what this patient has come in with
and how you would manage this patient
SLIDE 11
Mini History 3
ì 50 year old male presents to GP with sharp
epigastric pain that radiates retrosternally
ì He has had this pain before, worse after eating and
when lying down
ì The pain is ‘burning’ and ‘pressurizing’ ì Obs are all fine, some epigastric tenderness
SLIDE 12
Mini History 3
ì GORD ì Less so BBI, think more GP + remember GORD is
clinical diagnosis not really one for investigations! But rule out the bad stuff!
ì Screen for ALARM symptoms. ì Investigations: trial PPI, consider UGIE (>55 or
ALARM), consider ambulatory pH monitoring
ì Management: reassure + advise lifestyle changes,
full dose PPI 4-8weeks….
SLIDE 13
Mini History 4
ì 33 year old man presents to A&E with sharp, chest
pain and fever. The triage nurse hands you his ECG…
ì Person 1: You are the FY1, take a short 5 minute
history
ì Person 2: Tell us what investigations you want to
run and why
ì Person 3: Tell us what this patient has come in with
and how you would manage this patient
SLIDE 14
Anyone fancy reporting findings?
SLIDE 15 Mini History 4
ì 33 year old man presents to A&E with sharp,
pleuritic chest pain worse on lying down, improved
ì Not relieved with nitrates, high pitched pericardial
friction rub
ì Has a fever ì Raised ESR, CRP and troponin ì Diffuse ST elevation and P-R segment depression
SLIDE 16
Mini History 4
ìPERICARDITIS ìBedside: Obs, ECG
(widespread ST elevation
ìBloods: FBC, WCC, CRP ìImaging:
SLIDE 17 More on ECG
Widespread ST elevation
SLIDE 18 More on ECG
Whilst ST elevation occurs in most leads it is usually absent or depressed in aVR and V1
SLIDE 19
Just so you are aware… a less sensitive finding is PR depression
SLIDE 20
SLIDE 21 Reporting on an ECG
ì
Demographics: patient name, DOB, PC.
ì
Report ECG time and date, if done in series mention this!
ì
Check calibration
ì
Comment on rate, rhythm, axis.
ì
Comment on P wave, PR interval, QRS complex, ST segment and T wave
ì
KNOW YOUR COMMON ECG ABNORMALITIES
SLIDE 22
Mini History 5
ì A 19 year old man presents to A&E with sudden,
sharp unilateral chest pain and acute SOB.
ì Person 1: You are the FY1, take a short 5 minute
history
ì Person 2: Tell us what investigations you want to
run and why
ì Person 3: Tell us what this patient has come in with
and how you would manage this patient
SLIDE 23
Mini History 5
ì A 19 year old man presents to A&E with sudden,
sharp unilateral chest pain and acute SOB.
ì Hyper-resonance, decreased breath sounds on
affected side.
ì Oxygen saturations of 91% ì CXR shows displaced lung markings, no history of
trauma
SLIDE 24
Mini History 5
ì SPONTANEOUS PNEUMOTHORAX ì Bedside: ECG ì Bloods: ABG ì Imaging: CXR ì Management depends on CXR
findings
SLIDE 25
Mini History 6
ì An 18 year old female presents to her GP with a
‘fluttery feeling’ in her chest associated with sweating and nausea
ì Person 1: You are the FY1, take a short 5 minute
history
ì Person 2: Tell us what investigations you want to
run and why
ì Person 3: Tell us what this patient has come in with
and how you would manage this patient
SLIDE 26
Mini History 6
ì ANXIETY ì Bedside: ECG and ICD-10
diagnosis of anxiety
ì Bloods: FBC and TFT ì Management: reduce caffeine,
reduce stress, beta blockers
SLIDE 27 Differentials for Chest Pain
Cardiac – MI, Angina, Pericarditis, aortic dissection Resp – PE, pneumonia, pleural effusion, asthma Trauma – Pneumthorax etc GI – GORD, gastritis, PUD, oesophageal tears/ rupture Other – Anxiety, costochondritis
SLIDE 28
CASE – History
ì Volunteer for introduction and 1st minute of
consultation
SLIDE 29
CASE – History
ì Volunteer to take presenting complaint
SLIDE 30
CASE- History
ì Volunteer to take medical, surgical, drug and family
history
SLIDE 31
CASE – History
ì Volunteer to take social history and
conclude/summarise.
SLIDE 32
CASE – History
ì Volunteer to present the case.
SLIDE 33
CASE – Overview
ì 67 year old male ì One hour history of squeezing, 8/10 chest pain
radiating to left shoulder and jaw
ì Came on while gardening, does not ease with rest ì PMH – Diabetes, hypertension, hyperlipidemia, IHD ì Pale, clammy, nauseous
SLIDE 34
Investigations? LINK IN CHAT! VOTE
SLIDE 35
Investigation results- Bedside
ì ECG: See next slide ì Obs: v HR = 123bpm v RR = 21 v T = 37.1 v O2 = 94% v BP = 162/90
SLIDE 36
ECG
SLIDE 37
ECG
ìECG: ST elevation in V1-V4,
tachycardia and a new onset left bundle branch block
SLIDE 38 Investigation results - Bloods
ì
FBC – Normal
ì
Lipid profile – high LDH
ì
High CRP
ì
Cardiac biomarkers:
v
Troponin raised – Need serial troponins to see rise, it may not be raised at time of presentation
v
CK-MB raised
v
Myoglobin raised
SLIDE 39
Cardiac Biomarkers
SLIDE 40
Imaging
ì Coronary angiography – can also be used as
management (PCI +/- Stent)
ì Transthoracic echo post MI – assess LV function ì Cardiac CT – considered as alternative to invasive
angiography
SLIDE 41
Management?
SLIDE 42 Management
ì
MONARCH
§
M- Morphine
§
O – Oxygen
§
N – Nitrates
§
A – Aspirin
§
R – Reperfusion
§
C – Clopidogrel*
§
H – Heparin
*Some trust guidelines now suggest ticareglor instead
SLIDE 43 Management
ì Long term – BASIC
- B – Beta- blocker
- A – Anticoagulants
- S – Statin
- A – ACEi/ARB
- C – Correction of risk factors
SLIDE 44
Management
ì Supportive care – fluids, oxygen etc ì Surgery – CABG if damage is extensive and cannot
be fixed any other way
SLIDE 45
Key points for histories
ì REMEMBER THE PATIENTS NAME ì Tip: before you go in to station say their name three
times, and try to think of differentials based on patient demographics
ì 4 magic questions ì Make it flow – don’t just SOCRATES for the sake of it
SLIDE 46
4 Magic Questions
ì Have you had the pain before? If yes, how is this
different?
ì Was the onset sudden or gradual? ì What were you doing when the pain came on? ì Has the pain gotten worse?
SLIDE 47 The big clues
ì Risk factors: T2DM, hypertension, hyperlipideamia
– rule in ACS as ddx
ì Long periods of immobility, pregnant or on the pill –
think PE
ì Drugs causing the problem? High caffeine, alcohol
and cannabis (Don’t forget these in the social)
ì Other none cardiac causes! Think of cardiac, resp,
GI – and show the examiner you are ruling these
SLIDE 48
FEEDBACK
ì Discuss how taking the history went ì Please use the feedback form to tell us what you
think!
SLIDE 49
Thank you!
