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OSCEAZY Cardiology History Station Elsa Harte History Instructions Role Foundation Year 1 Doctor (FY1) Setting Emergency Department Patient Mr Bruce Wayne, a 64 y/o male presents with chest pain. Take a focused history and Student task initiate a management plan including pertinent investigations. SPOT DIAGNOSIS A 54-year old man presents with severe crushing chest pain at rest. The pain ACUTE CORONARY SYNDROME radiates to the jaw and arm. He has a past medical history of type 2 diabetes and high cholesterol. He is a heavy smoker. A 24 year old woman presents with pleuritic left sided chest pain. She is not able PULMONARY EMBOLISM to take a full breath. She is currently on the COCP & recently travelled. She also has palpitations. A 55 year old man presents with very sudden onset tearing chest pain. The pain AORTIC DISSECTION radiates to his scapula. He has a significant history of hypertension and smoking. A 65 year old women presents with pleuritic chest pain that improves when she ACUTE PERICARDITIS sits up. The pain is sharp and does not last long. She recently had an upper respiratory tract infection and she still has a fever. There are ECG changes. A 60 year old woman presents with chest pain that develops when she walks up STABLE ANGINA the stairs. The pain resolves when she takes her GTN spray and 5 minutes after she rests. Her BMI is 32. A 26 year man presents with pleuritic chest pain in the middle of his hockey game. PRIMARY SPONTANEOUS There is no history of trauma. She has no venous thromboembolism risk factors PNEUMOTHORAX and no significant medical history. CHEST P AIN HISTORY – FOCUSED QUESTIONS FULL NAME, DATE OF BIRTH, AGE, OCCUPATION, SYMPTOM SCREENING HISTORY OF PRESENTING COMPLAINT PAST MEDICAL/ SURGICAL HISTORY SYSTEMS REVIEW SOCIAL/ FAMILY/ DRUG HISTORY SOCRATES • Palpitations • Family history of Show me where do you feel the pain • Shortness of breath cardiovascular disease Do you usually suffer from chest pain or History of hypertension/ diabetes/ high • Calf Swelling • Smoking → current or ex- is this new? Is the pain relieved by GTN cholesterol? • Nausea/Vomiting/Sweating smoker, pack years? spray? History of previous heart attacks? • Fever • Alcohol Is the pain relieved by rest? History of calf swelling? • Unexplained weight loss • Recreational drugs How long does it take for pain to go long haul flights? • Over-the-counter away? Immobility? • Night sweats medications e.g. NSAIDs, COCP Is the pain worse when you breathe in? History of recent surgery, malignancy, • Syncope/ dizziness • Allergies? Is the pain worse when you cough? pregnancy? Is the pain worse when you lie down? History of previous surgeries e.g. CABG • Housing, independent Is the pain related to/ worse after meals functionality • Psychological impact Was the pain at its worst when it started? How far can you walk before you get this pain?CONDITION HISTORY CONDITION HISTORY CONDITION HISTORY •- Central crushing chest • Pleuritic ‘sharp’ chest pain pain •- Pleuritic chest pain •- Worse on exertion • Sudden onset •- Shortness of breath •- Radiation to PULMONARY EMBOLISM • Shortness of breath ASTHMA •- Wheeze ACUTE CORONARY jaw/shoulder • Associated with red, EXCACERBATION •- Fever SYNDROME •- Shortness of breath swollen leg •- Increased inhaler use •- Nausea, sweating •- VTE risk factors •- Cardiovascular risk •- ‘Burning’ epigastric factors • Pleuritic chest pain pain •- Tearing chest pain • Sudden onset GASTRO- OESOPHAGEAL •- Worse after meals or •- Sudden onset PNEUMOTHORAX REFLUX lying flat •- Radiation to back •- Shortness of breath DISEASE •- Metallic taste in •- Shortness of breath •- Young teenage male mouth – AORTIC DISSECTION •- Nausea, sweating • Cough •- History of •- ‘Burning’ epigastric hypertension •- Pleuritic chest pain pain •- History of Marfan's •- Productive cough •- Improves/ worsens syndrome •- Green/blood-stained PNEUMONIA phlegm PEPTIC ULCER DISEASE with meals •- Shortness of breath •- Dyspepsia •- Fever •- Haematemesis •- Pleuritic chest pain •- Nausea •- Relieved by sitting up •- History of viral illness •- History of NSAID use or leaning forwards •- Worsened by lying flat •- Central chest pain •- Pleuritic chest pain •- Sudden onset ACUTE PERICARDITIS •- Shortness of breath •- Productive cough RUPTURED •- History of violent •- Fever OESOPHAGUS vomiting •- History of viral illness •- Shortness of breath •- History or recent or recent COPD EXCACERBATION •- Wheeze •myocardial infarction or •- Fever endoscopy rheumatoid arthritis •- Increased inhaler use •- Sharp localised chest •- Smoker COSTOCHONRITIS pain •- Point tendernessPRESENTING THE HISTORY PATIENT DETAILS & KEY PRESENTING COMPLAINT HISTORY OF PRESENTING COMPLAINT RELEVANT NEGATIVES RELEVANT PMH/PSH/SH/DH ICE TOP DIFFERENTIAL & WHY OTHER DIFFERENTIALS CHEST PAIN INVESTIGATIONS SPECIFIC EXTRA INVESTIGATIONS ANY CHEST PAIN ACS Stable Angina Aortic Pulmonary Acute Dissection Embolism Pericardidtis BEDSIDE ABCDE ASSESSMENT Basic observations Serial ECGs Cardio examination Resp examination Urine Dip Glucose BLOODS FBC Lipid Profile Lipid Profile Group & Save D-Dimer CRP LFTs Clotting Clotting Screen Crossmatch U&Es Screen HbA1c ABG HbA1c Troponin IMAGING AND Chest X-ray Consider Consider CT aortogram CTPA Consider SPECIAL TESTS coronary coronary echocardiogram angiogram angiogram (for pericardial effusion) ACUTE CORONARY SYNDROME ACUTE MANAGEMENT CHECK IF PATIENT IS TALKING AND IF THE AIRWAY IS PATENT A PERFORM AIRWAY MANOUEVERS & ADJUNCTS IF SIGNS OF AIRWAY COMPROMISE CHECK OXYGEN SATURATIONS ON PULSE OXIMETER B CHECK RESPIRATORY RATE PERCUSS AND AUSCULTATE THE CHEST, CHECK FOR TRACHEAL DEVIATION PERFORM AN ARTERIAL BLOOD GAS DELIVER 15L/MIN HIGH FLOW OXYGEN VIA A NON-REBREATHER MASK ASSESS FLUID BALANCE C CHECK PULSE, BLOOD PRESSURE AND CAPILLARY REFILL TIME CHECK HEART SOUNDS OBTAIN AN URGENT ECG AND START THREE LEAD CARDIAC MONITORING ESTABLISH INTRAVENOUS ACCESS WITH A WIDE-BORE PERIPHERAL CANNULA TAKE BLOODS FOR FBC, U&Es, LFTs, CRP, SERUM GLUCOSE AND TROPONIN LEVELS START FLUID RESUSCITATION IF APPROPRIATE GIVE IV MORPHINE (5-10mg TITRATED TO PAIN AND IF APPROPRIATE) GIVE GTN SPRAY (UNLESS MARKED HYPOTENSION/ BRADYCARDIA) GIVE ASPIRIN 300mg PO STAT GIVE ANTIEMETIC (e.g. IV CYCLIZINE 50mg STAT) CHECK AVPU LEVEL D CHECK IF PUPILS ARE EQUAL & REACTIVE TO LIGHT CHECK CAPILLARY BLOOD GLUCOSE AND BLOOD KETONE LEVELS INSPECT FOR SIGNS OF CARDIOVASCULAR DISEASE e.g. CABG scar E CHECK TEMPERATURE PERFORM URINALYSIS INSERT A CATHETER & CLOSELY MONITOR URINE OUTPUT REQUEST CHEST X-RAY ACUTE CORONARY SYNDROME ACUTE MANAGEMENT IF PATIENT BECOMES UNRESPONSIVE WITH NO SIGNS OF LIFE, BEGIN CPR DISCUSS WITH ON-CALL INTERVENTIONAL CARDIOLOGIST FOR URGENT PCI (IF STEMI) OFFER TO REASSESS ABCDE THE SBAR APPROACH Intro YOUR NAME YOUR GRADE & DEPARTMENT CLARIFY NAME & GRADE OF PERSON YOU ARE CALLING Situation REASON FOR CONCERN AND CALL PATIENT DETAILS PATIENT CURRENT LOCATION MOST PERTINENT PROBLEM Background ADMISSION DETAILS (IF APPLICABLE) SUMMARISE CLINICAL PRESENTATION & WORKING DIAGNOSIS RELEVANT PAST MEDICAL HISTORY, RISK FACTORS AND RED FLAGS RELEVANT MEDICATIONS RELEVANT INVESTIGATION RESULTS ALLERGIES Assessment NEWS SCORE: STATE BP, PULSE, RR, SpO2 & TEMPERATURE. EXAMINATION FINDINGS PENDING INVESTIGATIONS MANAGEMENT SO FAR OVERALL CLINICAL IMPRESSION Recommendation SUSPECTED DIAGNOSIS +/- DIFFERENTIALS WHAT NEEDS TO HAPPEN AND WHEN IT NEEDS TO HAPPEN IS THERE ANYTHING ELSE I SHOULD DO? SHOULD THIS PATIENT BE TRANSFERRED TO ANOTHER PLACE? THE SBAR APPROACH Setting Emergency Department Patient Bruce Wayne Age 64 • Severe crushing central chest pain started 1 hour ago Presenting • Pain radiating to left arm and jaw complaint • Short of breath, • Sweating • Hypertension Past medical • Type 2 Diabetes history • Osteoarthritis • Atrial fibrillation • Atorvastatin • Warfarin • Ramipril Drug history • Omeprazole • Ibuprofen • Metformin • Allergic to penicillin Family history • Father had heart attack at age 60 • Heavy smoker Social history • Office clerk Respiratory rate 28 per minute Oxygen saturations 92% on oxygen Observations Pulse 140 per minute Blood pressure 90/50 mmHg Consciousness Alert Temperature 36.9°C THE SBAR APPROACH Intro Hello, I’m OSCEazy, the FY1 doctor on-call in the emergency department. Is this the medical registrar? Situation I’m calling because I would like you to urgently review a patient who has presented acutely unwell. The patient is called Bruce Wayne, a 64 year old man, and I am concerned that he has developed an acute coronary syndrome. Background His symptoms started one hour ago including central chest pain radiating to the left arm and jaw with associated dyspnoea. He has multiple cardiac risk factors including hypertension managed with ramipril and type 2 diabetes managed with metformin. He also has a significant smoking history. An ECG was performed and showed ST elevation in the anterior and lateral leads. The chest x-ray and ABG were normal. Assessment The patient currently has a NEWS score of 13 due to being tachycardic at 140 bpm, hypotensive with a blood pressure of 90/50 despite a 500ml crystalloid STAT bolus. Respiratory rate is 28 and oxygen saturations are 92% on 100% oxygen via a 15L non-rebreather mask. He is alert and afebrile. I have started cardiac monitoring and given an antiemetic. I have also given aspirin 300mg, clopidogrel 300mg and morphine 5mg. I am still awaiting the results of blood tests including troponin levels. Recommendation This patient has suffered an anterolateral STEMI and needs an urgent assessment and should be transferred to the catherization lab for PCI. I would like to ask if there is anything else that you would like me to do for the patient. Would you also be able to come and review him as soon as possible, please? Thank you ACS MANAGEMENT SUSPECTED ACS IV Morphine 2.5-5mg A-E Assessment GTNgen Urgent ECG Aspirin 300 mg STEMI ACS MANAGEMENT STEMI Yes Presents within 12 hours of onset of chest paiNo AND PCI available in 2 hours Second Antithrombotic Antiplatelet Second Antithrombotic Antiplatelet PRASUGREL UNFRACTIONATED HEPARIN TICAGRELOR CLOPIDOGREL IF ON ORAL CONSIDER GP IIb/IIIa ANTITHROMBOTIC ANTICOAGULANT INHIBITORS CORONARY ANGIOGRAPHY Coronary IF FAILED CORONARY Angiography IF INDICATED REPERFUSION Coronary ECG 60-90 PCI Angiography minutes later Fibrinolysis ACS MANAGEMENT SUSPECTED ACS IV Morphine 2.5-5mg A-E Assessment Oxygen GTN Urgent ECG Aspirin 300 mg NSTEMI OR UNSTABLE ANGINA ACS MANAGEMENT NSTEMI OR UNSTABLE ANGINAMI TRANSTHORACIC ECHOCARDIOGRAPHY ANTITHROMBOTIC STRESS ECHOCARDIOGRAPHY ANGIOGRAPHY CORONARY CONSIDER ISCHAEMIA TESTING Calculate GRACE Score Low Risk Unstable Clinical Condition High/Intermediate Risk Ticagrelor/ Clopidogrel if Prasugrel/ Consider Immediate High bleeding Coronary Prasugrel Risk Ticagrelor Coronary Angiography Angiography +/- PCI within +/- PCI 72 hours ACUTE CORONARY SYNDROME CHRONIC MANAGEMENT CONSERVATIVE MEDICAL/ SURGICAL MDT APPROACH (GP, PHYSIOTHERAPISTS, CARDIOLOGISTS) • DUAL ANTIPLATELET THERAPY BETA FULL FUNCTIONAL ASSESSMENT (ASSESS BLOCKER FOR & MANAGE CO-MORBIDITIES) CHARITIES/ SOCIETIES e.g. BRITISH HEART • ACE-INHIBITOR FOUNDATION • STATIN LIFESTYLE CHANGES (EXERCISE, DIETARY CHANGES, CARDIAC • ALDOSTERONE ANTAGONIST (IF REHABILITATION) STOP SMOKING EVIDENCE OF LV dysfunction) DRIVING ADVICE SEXUAL ACTIVITY ADVICE History Station Role Medical Student Setting GP Mr Tony Stark, a 54 y/o male, has been recently diagnosed Patient with angina secondary to coronary artery disease Student Please have a discussion with the patient regarding his task diagnosis and answer any questions he may have EXPLAINING ANGINA TO A PA TIENT INTRODUCTION WHAT IS ANGINA Lifestyle Changes Brief History Patient’s risk factors Medications ESTABLISH THE PATIENT’S UNDERSTANDING How was it diagnosed? Surgery ICE Complications of Angina Driving & DVLA Advice OUTLINE DISCUSSION Support and Education Follow Up Role Foundation Doctor Setting Emergency Department Miss Romanoff, a 45 year old woman has Patient an electrocardiogram taken Student task electrocardiogram and make an appropriate management plan STUDENT INSTRUCTIONSINTERPRET THIS ECGINTERPRET THIS ECGTACHYCARDIABRADYCARDIAINTERPRET THIS ECGINTERPRET THIS ECGINTERPRET THIS ECGINTERPRET THIS ECGINTERPRET THIS ECGINTERPRET THIS ECGADULT ADVANCED LIFE SUPPORT Role Medical student Setting A&E Patient Mrs Incredible, a 36 y/o female presents with palpitations. Take a concise history from the patient regarding his presenting symptoms. Student task At 7 minutes, the examiner will stop you, ask you to summarise your findings and present a differential diagnosis. STUDENT INSTRUCTIONS P ALPIT A TIONS HISTORY – FOCUSED QUESTIONS FULL NAME, DATE OF BIRTH, AGE, OCCUPATION, SYMPTOM SCREENING SOCIAL/ FAMILY/ DRUG HISTORY HISTORY OF PRESENTING COMPLAINT PAST MEDICAL/ SURGICAL HISTORY SYSTEMS REVIEW SOCRATES Chest pain Family history of What do you mean by palpitations? History of hypertension/ diabetes/ high Shortness of breath cardiovascular disease Do you usually suffer from palpitations, cholesterol? Calf Swelling Family history of sudden death or is this new? History of previous heart attacks? Nausea/Vomiting/Sweating Smoking → current or ex- Have you got palpitations right now? History of heart valve disease? Change in periods smoker, pack years? Alcohol Can you tap the rhythm of the History of thyroid disease? Fever Recreational drugs palpitations? History of anxiety/ depression/ panic? Unexplained weight loss Caffeine, Beta-agonists, Do you feel like your heart skips a beat? Night Sweats Syncope/Dizziness Nicotine Is there anything obvious that triggers Over-the-counter medications, the palpitations? e.g. NSAIDs, Allergies? What happens before the palpitations Housing, independent start? functionality Have you been experiencing any anxiety Psychological impact Have you experienced any change in mood? Have you been experiencing any stress/ sleep changes?INTERPRET THIS ECGINTERPRET THIS ECG A TRIAL FIBRILLA TION CONDITION HISTORY ATRIAL FIBRILLATION •- Elderly patient •- History of cardiovascular disease e.g. valve disease •- History of recent infection SUPRAVENTRICULAR TACHYCARDIA •- Episodes terminated by vagal manoeuvres e.g. blowing the nose •- History of COPD multifocal atrial tachycardia VENTRICULAR TACHYCARDIA - Symptoms of haemodynamic instability/ systemic compromise - History of recent myocardial infarction - History of ischaemic heart disease THYROTOXICOSIS Symptoms of hyperthyroidism - History of thyroid disease - History of autoimmune diseases (Grave’s Disease) EXCESS CAFFEINE INTAKE - Self-limiting palpitations - Diagnosis of exclusion HYPOGLYCAEMIA - History of diabetes mellitus/ liver disease/ Addison’s disease - History of hypoglycaemic drugs (e.g. insulin, sulfonylurea) - Sweating, hunger, dizziness, confusion OTHER DIFFERENTIALS OTHER DIFFERENTIALS - Pheochromocytoma - Fever - Simple anxiety/ Generalised anxiety disorder - Ventricular ectopic - Other medications e.g. beta-agonists, cocaine P Pulmonary causes (PE, COPD, Pneumonia I Ischaemic Heart Disease/ Idiopathic R Rheumatic Heart Disease/Valvular Heart Disease What are the A Alcohol/ Anaemia/ Advanced Age causes of atrial fibrillation? T Thyrotoxicosis/oxins E Elevated blood pressure S Sepsis/ Sleep apneoa Investigations BEDSIDE Bloods IMAGING & SPECIAL TESTS • FBC • Basic observations • Chest X-Ray • ECG • HBa1c • Echocardiography • LFTs • Cardio • 24 hour ECG (For examination • U&Es paroxysmal AF) • Resp examination • BNP • Urine Dip • Lipid Profile • Glucose ACUTE AF MANAGEMENT ABCDE ASSESSMENT Shock Syncope Haemodynamically Stable Haemodynamically Unstable Heart Failure Chest Pain Check Anticoagulant Status Electrical Synchronised DC Cardioversion None Onset > 48 hours Onset < 48 hours or unclear Anticoagulation and either rate or Anticoagulation for a rhythm control minimum of 3 weeks and Elective (immediate cardioversion) Cardioversion rate control Anticoagulation in AF ASSESS STROKE RISK USING ASSESS BLEEDING RISK USING ORBIT CHA2DS2-VASc SCORE SCORE C -- Congestive heart failure (1 point) H – Hypertension (1 point) A2 – Age ≥ 75 (2 points) D – Diabetes Mellitus (1 point) S2 – Stroke / TIA / thromboembolism history (2 points) V – Vascular disease e.g. prior MI, aortic plaque (1 point) A – Age 65-74 (1 point) Sc – Female Sex (1 point) CHA2DS2-VASc >/= 2 : offer oral anticoagulant •DOAC OFFERED 1st LINE •WARFARIN OFFERED IF DOAC CHA2DS2-VASc = 1 in men:consider oral anticoagulant CONTRAINDICATED CHA2DS2-VASc ≤ 1 in women or CHA2DS2-VASc = 0 in men do not offer an anticoagulant AF Management RATE CONTROL RHYTHM CONTROL OFFERED 1st LINE UNLESS: •AF has a reversible cause • PHARMACOLOGICAL: •Patient has heart failure thought to be • Flecainide or Amiodarone caused by AF • SYNCHRONISED DC CARDIOVERSION •Patient has new-onset AF • Amiodarone considered 4 weeks before and up to 12 •Patient has atrial flutter and their condition is months after electrical cardioversion suitable for ablation •Rhythm control strategy is more suitable based on clinical judgement FOR SYMPTOMATIC AF THAT IS REFRACTORY TO DRUG TREATMENT, CONSIDER LEFT ATRIAL ABLATION OR PACE & ABLATE Role Medical student Setting GP Mr Dumbledore, a 76 y/o male has a history of heart Patient failure. Student task Please take a focused history regarding his symptoms STUDENT INSTRUCTIONS HEART FAILURE WITH REDUCED EJECTION FRACTION ACE-INHIBITOR + BETA-BLOCKER ADD SPIRONOLACTONE CONSIDER ADDING Consider MEDICATION Intervention HYDRALAZINE/ NITRATE SACUBITRIL/VALSARTAN IMPLANTABLE CARDIAC DEFIBRILLATOR CARDIAC RESYNCHRONISATION (IF SYMPTOMATIC, EF<35% & QRS ≥ 130 ms) CARDIAC TRANSPLANTATION Focused Questions • Are you short of breath when you lie down? • Do you wake up at night short of breath? • How many pillows do you sleep with at night? • Do you have difficulty walking? • Have you had any recent illness or surgery? • How much could you exercise previously? • How far can you walk before getting short of breath? • How have the symptoms affected your daily living? SHORTNESS OF BREATH ORTHOPNEA PAROXYSMAL NOCTURNAL DYSPNOEA FATIGUE ANKLE SWELLING HEART FAILURE A CHECK IF PATIENT IS TALKING AND IF THE AIRWAY IS PATENT CONSIDER PERFORMING AIRWAY MANOEUVERS IF SIGNS OF AIRWAY COMPROMISE B CONSIDER PERFORMING AIRWAY MANOEUVERS IF SIGNS OF AIRWAY COMPROMISE ACUTE POSITION PATIENT SITTING UPRIGHT CHECK OXYGEN SATURATIONS ON PULSE OXIMETER CHECK RESPIRATORY RATE PERCUSS AND AUSCULTATE THE CHEST, CHECK FOR TRACHEAL DEVIATION PULMONARY PERFORM AN ARTERIAL BLOOD GAS DELIVER 15L/MIN HIGH FLOW OXYGEN VIA A NON-REBREATHER MASK CONSIDER CPAP OR INVASIVE VENTILATION IF HYPOXIA DOES NOT IMPROVE OEDEMA C ASSESS FLUID BALANCE CHECK PULSE, BLOOD PRESSURE AND CAPILLARY REFILL TIME. ACUTE CHECK HEART SOUNDS & EXAMINE JUGULAR VENOUS PRESSURE OBTAIN AN URGENT ECG AND START THREE LEAD CARDIAC MONITORING ESTABLISH INTRAVENOUS ACCESS WITH TWO WIDE-BORE PERIPHERAL CANNULAS TAKE BLOODS FOR FBC, U&Es, MANAGEMENT CRP, TROPONIN & BNP LEVELS URGENTLY SEEK CRITICAL CARE & CARDIOLOGIST INPUT IDEALLY BEGIN FLUID-RESTRICTION BE CAUTIOUS WITH FLUID RESUSCITATION TO CORRECT HYPOTENSION CONSIDER ADMINISTERING IV FUROSEMIDE D CHECK AVPU LEVEL/ GCS CHECK IF PUPILS ARE EQUAL & REACTIVE TO LIGHT CHECK CAPILLARY BLOOD GLUCOSE AND BLOOD KETONE LEVELS E INSPECT FOR SIGNS OF CARDIOVASCULAR DISEASE CHECK TEMPERATURE PERFORM URINALYSIS INSERT A CATHETER & CLOSELY MONITOR URINE OUTPUT REQUEST CHEST X-RAY & ECHOCARDIOGRAM CHRONIC HEART FAILURE MANAGEMENT CONSERVATIVE MEDICAL/ SURGICAL • MDT APPROACH (GP, • AS PER FLOW CHART PHYSIOTHERAPISTS, • OFFER ANNUAL INFLUENZE & ONE-OFF CARDIOLOGISTS) PNEUMOCOCCAL VACCINATION • FULL FUNCTIONAL • FLUID RESTRICTION (TYPICALLY <1.5L ASSESSMENT (ASSESS FOR & PER DAY) MANAGE CO-MORBIDITIES) • CHARITIES/ SOCIETIES e.g. BRITISH HEART FOUNDATION • LIFESTYLE CHANGES (EXERCISE, DIETARY CHANGES, REDUCE ALCOHOL) • STOP SMOKINGPLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK