ì Chest Pain StudyHub OSCE History Taking Session
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
Vote for investigations anonymously
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
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
Mini History 1 AORTIC DISSECTION ì Bedside: ECG – exclude cardiac pathology ì Bloods: FBC (Hb drop), U+E (pre-renal AKI due to hypoperfusion), ì troponin, group and save, cross match, clotting screen, lactate, d- dimer Imaging: CXR (widened mediastinum), CT angiogram ì Management: ABCDE approach, high flow oxygen, IV access, fluid ì resus (cautiously). Then depends on type. Type A = surgical, Type B uncomplicated = medical Long term: antihypertensive therapy and surveillance imaging ì
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
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
Mini History 2 ì MALLORY-WEISS SYNDROME Longitudinal mucosal tears, usually at the gastro-oesophageal ì junction Bedside: Obs (HR,RR,BP… etc determine if stable), calculate ì Glasgow Blatchford score, monitor fluid status Bloods: FBC (anaemia), VBG (lactate), clotting, G+S, crossmatch, ì urea (if high suggests significant fluid loss) Imaging: erect CXR ì Management: ABCDE approach, IV access, fluid resus, endoscopy ì (diagnostic and therapeutic) +/- antibiotics and terelepressin
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
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
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….
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
Anyone fancy reporting findings?
Mini History 4 ì 33 year old man presents to A&E with sharp, pleuritic chest pain worse on lying down, improved on leaning forward 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
Mini History 4 ì PERICARDITIS ì Bedside: Obs, ECG (widespread ST elevation ì Bloods: FBC, WCC, CRP ì Imaging:
More on ECG Widespread ST elevation
More on ECG Whilst ST elevation occurs in most leads it is usually absent or depressed in aVR and V1
Just so you are aware… a less sensitive finding is PR depression
Reporting on an ECG Demographics: patient name, DOB, PC. ì Report ECG time and date, if done in series mention ì this! Check calibration ì Comment on rate, rhythm, axis. ì Comment on P wave, PR interval, QRS complex, ST ì segment and T wave KNOW YOUR COMMON ECG ABNORMALITIES ì
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
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
Mini History 5 ì SPONTANEOUS PNEUMOTHORAX ì Bedside: ECG ì Bloods: ABG ì Imaging: CXR ì Management depends on CXR findings
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
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
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
CASE – History ì Volunteer for introduction and 1 st minute of consultation
CASE – History ì Volunteer to take presenting complaint
CASE- History ì Volunteer to take medical, surgical, drug and family history
CASE – History ì Volunteer to take social history and conclude/summarise.
CASE – History ì Volunteer to present the case.
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
Investigations? LINK IN CHAT! VOTE
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
ECG
ECG ì ECG: ST elevation in V1-V4, tachycardia and a new onset left bundle branch block
Investigation results - Bloods FBC – Normal ì Lipid profile – high LDH ì High CRP ì Cardiac biomarkers: ì Troponin raised – Need serial troponins to see rise, it v may not be raised at time of presentation CK-MB raised v Myoglobin raised v
Cardiac Biomarkers
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
Management?
Management MONARCH ì M- Morphine § O – Oxygen § N – Nitrates § A – Aspirin § R – Reperfusion § C – Clopidogrel* § *Some trust H – Heparin guidelines now § suggest ticareglor instead
Management ì Long term – BASIC B – Beta- blocker • A – Anticoagulants • S – Statin • A – ACEi/ARB • C – Correction of risk factors •
Management ì Supportive care – fluids, oxygen etc ì Surgery – CABG if damage is extensive and cannot be fixed any other way
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
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?
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