Gen Med Station 6

Setting:

You are a junior doctor working in A+E. This patient presents with chest pain.

Name: Samuel Brown

Tasks:

1. Take a history from the patient.

2. State which investigations you would like to the patient.

3. Interpret the provided investigations to the examiner.

4. Give your preferred diagnosis and management to the examiner.

You are not required to examine the patient.

Briefing

Diagnosis: STEMI presenting with chest pain.
You are Samuel Brown (57 years old).
You have presented to A&E after developing chest pain.

Appearance and Behaviour

You should act anxious, mostly because in the back of your head you knew this could be serious and ignored it. Now it's getting worse and you're very scared you might end up very sick so you really want the doctor to take you seriously. .

Opening statement

I was at work this morning when I suddenly got a really bad pain in my chest and after a while when it wouldn’t go I started getting a bit worried so came here.

Information to Give Freely

I was sat at my desk at work when I got a really heavy pain in the middle of my chest. I’ve had it a few times in the past but that always went away and this time it hasn’t.

Presenting Complaint

Site - Right in the middle of your chest
Onset - started about 3 hours ago, it was very sudden. is constant and has become worse with time.
Character - it feels like someone is squeezing your chest (tight/heavy), and if asked it is continuous.
Radiation - it is spreading up your chest but not into your arm of neck
Associated symptoms - You feel a bit sick but haven’t vomited and your chest feels like it’s pumping really fast/pounding. You also think you’re quite sweaty.
Timing - It’s been worsening since it started.
Exacerbating/alleviating factors - You tried taking tablets for indigestion but that hasn’t helped. Walking makes it worse.
Severity - Initially 4/10, now 7-8/10

Past Medical History

Previous similar episodes - Every 2-3 days over the last month of similar (but milder) pain in the middle of your chest when you were walking. It felt a bit like a stitch and the pain always went away after about 15 minutes, especially if you just took a rest so you hadn’t seen your GP about it.
Other medical conditions - Depression, Hayfever
Previous surgeries - Nil

Drug History

Prescribed - Sertraline, Cetirizine
Over the counter - Paracetamol, Gaviscon - neither has worked
Allergies - Penicillin. You find it really difficult and get a bad rash all over your body.

Family History

Your mum had a stroke in her 80s.

Social History

Smoking - 10 cigarettes a day. Started when you were 20. So smoked for 37 years (18.5 pack years)
Alcohol - About 5 pints over the weekend. Nil on weekdays.
Job - Manager for a recruitment company. Your job is quite stressful.
Exercise - Occasional. You don’t really have the time to work
Home - lives alone in a house
Mobility - Completely independent normally.
ADLs - Completely independent in washing, cooking, cleaning etc.

Systems Review

General/red flags - Fevers, weight loss, night sweats
Neuro - No Loss of consciousness, change in sensation, change in movement
Resp - No shortness of breath, haemoptysis or infective symptoms
Cardio - No Palpitations. Chest pain as per PC.
GI - Nausea. No change in bowel habits, haematemesis or malaena
GU - No Frequency, urgency, dysuria or haematuria
Joints - No fractures, swellings or stiffness

Ideas / Concerns / Expectation

Ideas - Worried that you’re having a heart attack.
Concerns - What if it’s serious and you can’t get back to work.
Expectations - You want the doctor to take your pain seriously.

Discussion / Questions

If candidate does not address expectation of pain being taken seriously (either by not asking it or not reassuring you about you mention you want it taken seriously) you should get upset and threaten to leave and go somewhere else that will take you seriously.