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OSCE SERIES THE CARDIOLOGY STATION MOVIN PERAMUNA GAMAGE PROUDLY IN COLLABORATION WITH Role Medical student Setting Emergency department STUDENT Patient David Adams, a 64 year old man presents with chest pain INSTRUCTIONS Student task Take a history from him. At 7 minutes, the examiner will stop you, ask you to summarise your findings and present a differential diagnosis. HISTOR Y HISTORY OF PRESENTING COMPLAINT • • • • • • • SYSTEMS REVIEW • • HISTOR Y PAST MEDICAL HISTORY FAMILY HISTORY • • • • DRUG HISTORY • ICE • • SOCIAL HISTORY • • • • • • • SUMMARISING THE HISTORY Patient details, occupation I took a history from David Adams, a 62-year-old man who came in with acute onset chest pain & key presenting complaint The pain is constant, central, came on suddenly 2 hours ago, described as a sharp/’stabbing’ History of presenting complaint pain and moves to the back. He also feels nauseous and light-headed. The pain does not seem to spread down his left arm. It came on while he was jogging in the park. Nothing seems to He has never experienced any pain like this before.e. Resting did not improve the pain either. Relevant negatives No fever, cough, palpitations, SOB, feelings of lightheadedness or leg swelling. Relevant PMH/PFH/SH/DH has a 20-year pack history but has been trying to quit. He does not consume alcohol or use recreational drugs. He is retired and lives in a 2-bedroom apartment with his partner. Ideas, concerns & expectations He is worried he is having a heart attack and wants pain relief immediately. Top differential & why My top differential is Aortic dissection. Other differentials PE.er differentials that I would like to rule out are Myocardial infarction/ACS, pericarditis andSPOT DIAGNOSIS ACUTE CHEST P AIN CARDIAC RESPIRA TORY OTHER • Myocardial infarction • Pulmonary embolism • Musculoskeletal • Aortic dissection • Pneumothorax • GORD • Pericarditis • Pneumonia • Anxiety/panic attack • Myocarditis • Costochondritis INVESTIGA TIONS TEST JUSTIFICATION A-E For any acutely unwell patient always start with the A-E approach! Always remember to ask for Senior Support! BEDSIDE Basic observations All patients should have this, especially pulse oximetry Cardiac and/or Respiratory Examination To look for cardiac pathology, e.g. expiratory wheeze on auscultation or ENT pathology 12-lead ECG To look for signs of cardiac disease Full blood count (FBC) Assess for signs of infection Urea and Electrolytes (U&Es) Assess for electrolyte abnormalities LFT Assess for liver function BLOODS CRP To look for signs of inflammation, e.g. secondary to infection Troponin To investigate for ACS D-dimer To rule out PE depending on well’s score CXR To look for aortic dissection, respiratory causes IMAGING CT scan/angiography To look for aortic dissection, investigate other cardiac disease ECHO To investigate cardiac disease, e.g. to look for aortic dissection in haemodynamically unstable patient SPECIAL TESTS - - DA T A INTERPRET A TION • A – Airway (trachea position & patency) • B – Breathing (lung fields & margins) • C – Cardiac (only on PA CXR, cardiomegaly) • D – Diaphragm (blunting of costophrenic angles due to lower lobe pneumonia, etc) • E – Everything else (bones, mediastinum etc) https://emj.bmj.com/content/24/4/310.1 • Widened mediastinum due to aortic dissection • Loss of aortic knuckle contour AORTIC DISSECTION MANAGEMENT • Educate patient about the • Offer pain relief • Surgical management of condition – e.g. provide • IV beta-blockers Stanford type A aortic leaflets/website links • Supportive treatment, e.g. dissection • Safety netting patient if fluids, oxygen symptoms worsen after discharge • Warn about possible complications, e.g. stroke • Lifestyle modification, e.g. stop smoking, RF control ACS MANAGEMENT • Educate patient about the • MONA +/- 2 antiplatelet • CABG if severe disease, e.g. condition – e.g. provide if STEMI triple vessel disease leaflets/website links • Urgent PCI/fibrinolysis • Make sure patient is • Medications for secondary comfortable prevention, e.g. ACE-I, • Warn about possible beta-blocker, statin complications, e.g. heart • GRACE score and failure fondaparinux for NSTEMI • Lifestyle modification, e.g. and UA stop smoking, RF control • Cardiac rehabilitation PERICARDITIS MANAGEMENT • Educate patient about the • Admit if severe (e.g. high • Nil condition – e.g. provide fever, elevated troponin) leaflets/website links • Treat underlying cause • Reassure majority of • NSAIDs and colchicine for patients are treated idiopathic/viral pericarditis conservatively • Monitor recovery using • Advise to avoid strenuous inflammatory markers, e.g. activity until symptom CRP resolution • Safety netting patient if symptoms worsen • • CHEST P AIN HX • KEY POINTS • • THANK YOU FOR LISTENING! PLEASE FILL OUT THE FEEDBACK FORM PLEASE TUNE IN TO OUR REMAINING SESSIONS THIS WEEK