Gen Med Station 2

Setting:

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

Name: Chester Payne

Tasks:

1. Take a history from the patient.

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

3. Interpret the provided investigations.

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

You are not required to examine the patient.

Briefing

Diagnosis: MI presenting with a chest pain
You are Mr Chester Payne, a 69 year old male.
You have presented to A+E with centralised chest pain.

Appearance and Behaviour

During consultation you should act slightly flustered and hold your chest.

Opening statement

“I’ve had this weird pain in my chest since this morning and nothing is helping, please help doctor”

Information to Give Freely

It started when I was trying to get some chocolate from the top shelf this morning. I’ve been having similar pains for the past few weeks but it always goes away, this time it won’t go away so I thought I should come and get it checked out properly.

Presenting Complaint

Site - right in the middle of the chest.
Onset - it came on very quickly this morning. It’s gotten slightly worse since it started.
Character - it’s like pressure, like someone is sitting on my chest.
Radiations - it’s getting worse now and spreading to my neck.
Associated symptoms -

Sweating

Clammy

Nausea (but you have NOT vomited)

Mild dizziness

Timing - It’s been getting slightly worse since it started this morning
Exacerbating/relieving factors - I was climbing the cupboards to reach the top shelf to get some chocolate when it started. I’m usually very inactive so I thought I'd just pulled a muscle with all the extra “exercise”. Sitting down makes it better but it won’t go away.
Severity - 7/10

Past Medical History

Previous similar episodes - I’ve had similar episodes of pain like this over the last few weeks but I just ignored it and it went away. The pain came about once a day last week.
Other medical conditions - Peripheral vascular disease, high cholesterol, Type 2 Diabetes, hypertension, always struggled to maintain a healthy weight.
Previous surgeries - nil

Drug History

Prescribed - Ramipril and Rosuvastatin
Over the counter - Nil
Allergies - None

Family History

Dad died of a heart problem at 72 years old, you can’t remember the details.

Social History

Smoking - 10 cigs/day for about 40 years.
Alcohol - Nil.
Job - Office Worker
Exercise - You're very sedentary and rarely exercise.
Diet - Your diet is very poor, if asked state "i'd eat takeout for every meal if I could afford it"

Systems Review

ENT - Mild dizziness.
Resp - Mild breathlessness, the pain is NOT related to breathing.
Cardio - No palpatations
MSK - the pain is NOT made worse by movement.
No other symptoms

Ideas / Concerns / Expectation

Ideas - “I thought it might be muscular from reaching on top of cupboards this morning.”
Concerns - “It’s not resolving so i’m a bit worried it might be the same as what my dad had and I could be dying?" Ask the doctor “am I going to die?”
Expectations - “I want to know what’s causing the pain.”

Discussion / Questions

After the history is complete the doctor will discuss further tests and treatment with the examiner, please have no further input as the patient.

Name: Mr Chester Payne

DoB: 01.06.1952

Date of Study:

ECG source : https://litfl.com/st-depression-does-not-localise/

Troponin
260 (reference 0-14 ng/L)