Chest Pain Hx OSCE

Chest Pain?

Table of Contents

• Case Studies
  • Case-3: Chest Pain
    • Patient Brief Record / Brief Scenario
      • Information for Student about the Case
      • TASK: (What is expected from a student?)
    • Patient Brief Record / Brief Scenario
      • Information for the Simulated Patient
      • Important Notes for the Simulated Patient
    • Notes

Case Studies

Case-3: Chest Pain

Patient Brief Record / Brief Scenario

Information for Student about the Case

• Patient Name: Ahmad
• Age: 50 years
• Occupation: Employee at a private company
• Today BP: 150/90 mm Hg
• Weight: 90 kg
• Height: 170 cm

Mr. Ahmad is a 50-year-old man who has been experiencing chest pain on and off for the past few weeks.

TASK: (What is expected from a student?)

• Take a focused history to reach a probable diagnosis.
• Perform a cardiovascular system examination.
• Inform the patient about the possible diagnosis.
• Provide appropriate advice regarding lifestyle modifications.
• Explain the management plan to the patient.

Patient Brief Record / Brief Scenario

Information for the Simulated Patient

• Patient Name: Ahmad
• Age: 50 years
• Occupation: Employee at a private company
• Marital Status: Married, with 2 children (18 and 20 years old).

You are a 50-year-old man who works as an employee at a private company. For the past few weeks, you have been experiencing on-and-off chest pain.

Opening Scenario: “I have chest pain, doctor.” (You will admit only this information.)

Tell your doctor about the following information only if specifically asked about:

• Complaint of chest pain over the past few weeks.
• Pain usually comes on exertion, especially when climbing stairs.
• No history of trauma.
• You smoke 20 cigarettes per day.
• You have gained about 10 kg in the past 6 months.
• You are generally well apart from this chest pain.
• Your working hours are 8:00 AM to 5:00 PM.
• Some stress at work when you have to do too much paperwork.
• No stress at home.
• Your BP was taken by the nurse today and was found to be slightly high, repeated twice.
• You lead a sedentary lifestyle with no regular exercise.
• Your father died of a heart attack at the age of 55.
• Your mother is diabetic and hypertensive.
• Patient’s Idea: Possibly hypertension.
• Concern: Heart attack, as your father had one.
• Expectation: To confirm the diagnosis of hypertension to start treatment.

SAY NO TO ANY OTHER QUESTIONS RELATED TO ANY SYMPTOMS.

Important Notes for the Simulated Patient

• The doctor will examine your chest to confirm the diagnosis.

Chest Pain (Myocardial Infarction)

CANDIDATE SHOULD COVER THE FOLLOWING

Differential Diagnoses to Consider

• MI, pneumothorax, aortic dissection, PE, pneumonia, MSK.

History

Information Gathering

• Introduce yourself, take permission.
• Doctor asks more details about chest pain: onset, duration, frequency, location, radiation, severity, aggravating and relieving factors, character.
• Associated symptoms (SOB, sweating, vomiting, nausea, epigastric pain, syncope, anxiety, lightheadedness, cough).

CVS Risk Assessment

• Obesity, smoking, exercise, age.

Past Medical History

• Hx of similar attacks.
• Hx co-morbidities (DM, dyslipidemia, IHD, HTN, asthma).

Medication History

Family History

• HTN, cardiac disease, stroke, DM, and sudden death.

Social History

• Marital status, job, stressful life events, and hobbies.

Examination

• ABC.
• General Appearance, Vital Signs: repeat BP in both arms, oxygen saturation.
• Fundoscopy: for hemorrhage and papilledema.
• Chest Examination: heart sounds, added sounds, lung crepitations.
• Abdomen: abdominal bruit.
• Lower Limbs: edema and peripheral pulses (dorsalis pedis, popliteal, femoral).

Investigation (According to History and Examination Findings)

• CBC, electrolytes, BUN/Cr, ECG, chest x-ray, cardiac enzymes (CK, troponin T/I), D-dimer.

Management (CRAPRIOPS)

• IF the Case is Acute MI (ECG changes of ST elevation at least 1mm in two leads):
  • Rapid history and physical examination.
  • Immediate stabilization.
  • Call ambulance and arrange to transfer to ER.
  • Transfer to observation room.
  • MONA:
    • Morphine sulfate 2-4 mg IV + O2 (if oxygen sat. <90%).
    • Sublingual Nitroglycerin (0.3-1.0mg sublingual every 5min - max. 3 doses).
    • ASA 300 mg.
    • I.V. line + cardiac monitor.
  • TTT at Hospital: PCI (within 90min) or thrombolysis (within 12hr of onset).
  • Contraindications to Thrombolytic: H/O CVA within 6m.

Doctor/Patient Interaction / Effective Use of Consultation

• Understanding the Patient’s Perspective: Ideas, Concerns, and Expectations.
• Non-Verbal Behavior: eye contact, posture and position, movement and expression.
• Demonstrates Interest, Concern, Respect: for the patient as a person (throughout the interview).
• Encourages Patient to Talk.
• Uses Open-Ended and Closed Questions: as appropriate.
• Listening: listens attentively, allowing patient to complete statements without interruption and leaving space for patient to think.
• Facilitation: facilitates patient’s responses verbally and non-verbally (e.g., use of encouragement, silence).
• Internal Summary: periodically summarizes to verify own understanding of what the patient has said; invites patient to correct interpretation or provide further information.
• Uses Concise, Easily Understood Questions and Comments: avoids or adequately explains jargon.
• Promote Informed Decision Making.
• Attends to Timing.