[vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][ultimate_heading main_heading=”Candidate brief” main_heading_color=”#000000″ sub_heading_color=”#000000″ main_heading_style=”font-weight:bold;” main_heading_font_size=”desktop:36px;”]

Your Role: you are the doctor on duty for the Acute Medical Unit.

You have 10-minutes with each patient. The Examiners will alert you when 6-minutes have elapsed and will stop you after 8-minutes.

In the remaining 2-minutes, one examiner will ask you to report on any abnormal physical signs elicited, your diagnosis or differential diagnoses, and your plan for management (if not already clear from your discussion with the patient).

Scenario

Mr Mike O’Dyllan (30-years)

GP Ketter: Please see this young man who had sudden chest pain. Please exclude aortic dissection.

Please advise on how to investigate and manage

Physiological observations

Respiratory rate / minute: 16

Pulse rate / minute: 74

Systolic blood pressure (mmHg): 124

Diastolic blood pressure (mmHg): 72

Oxygen saturations (%): 98

Temperature: 36.4°

Your task is to:

Assess the problem by means of a brief focused clinical history and a focused relevant physical examination. You do not need to complete the history before carrying out an appropriate examination.

Advise the patient of your probable diagnosis (or differential diagnoses), and your plan for investigation and treatment where appropriate. Respond directly to any specific questions which the patient may have.

[/ultimate_heading][vc_empty_space image_repeat=”no-repeat”][vc_video link=”https://vimeo.com/198684440″][vc_empty_space image_repeat=”no-repeat”][vc_row_inner row_type=”row” type=”full_width” use_row_as_full_screen_section_slide=”no” text_align=”left” css_animation=””][vc_column_inner width=”1/4″][no_counter type=”zero” box=”no” position=”center” underline_digit=”no” separator=”yes” digit=”20″ title=”Minutes” text=”Station time”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” box=”no” position=”center” separator=”yes” digit=”10″ title=”Minutes” text=”Time for this encounter”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” position=”center” separator=”yes” digit=”8″ title=”Minutes” text=”Maximum time to examine your patient”][/vc_column_inner][vc_column_inner width=”1/4″][no_counter type=”zero” position=”center” separator=”yes” digit=”2″ title=”Minutes” text=”Minimum time for discussion and questions”][/vc_column_inner][/vc_row_inner][vc_empty_space image_repeat=”no-repeat”][/vc_column][/vc_row][vc_row row_type=”row” use_row_as_full_screen_section=”no” type=”full_width” oblique_section=”no” text_align=”left” css_animation=””][vc_column][vc_accordion style=”accordion”][vc_accordion_tab title=”Common examiner questions”][vc_column_text]Common examiner questions include the following:

  1. What do you think this patient has?
  2. How would you like to investigate this patient next?
  3. What do you think the underlying cause of this patient’s signs is?

[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Diagnosis and clinical signs”][vc_column_text]This young man has musculoskeletal chest pain from playing sport. He has normal heart and lung sounds.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Discussion”][vc_column_text]

Chest pain is one of the most common, and yet one of the most difficult presenting complaints with many causes. Anatomically, the pain can arise from the muscles and bones of the chest wall, lungs, upper gastrointestinal tract, or abnormalities in nerve pain sensation, but the most concerning is from the heart due to the high risk of death in coronary artery disease.

Due to the multiple anatomical structures in and around the chest, it can be difficult to distinguish one cause of chest pain from another. As with most of medicine, the history is the key. It would be very easy to test for ‘everything’ and then have difficulty understanding the results. By focusing on the pain, you can focus the investigations.

Outside of traumatic causes of chest pain, the four most serious causes are:

  • Acute coronary syndrome (ACS; encompassing acute myocardial infarction and unstable angina) – most common
  • Pulmonary embolism
  • Aortic dissection
  • Spontaneous pneumothorax

Typical Symptoms of Cardiac Chest Pain:

  • Pain similar to a previous acute myocardial infarction
  • Chest pain that is worse on exertion, or chest pain occurring at rest in someone with previous angina
  • No or poor response to analgesia within appropriate period of time
  • Pain occurring for 60-minutes or more
  • Pain over the preceding 24 hours, escalating in nature
  • Pain within 6-weeks of an acute myocardial infarction or revascularisation

Features to explore to help determine if the chest pain is potentially cardiac in origin include

  • the presence of cardiovascular risk factors (hypertension, high cholesterol, positive family history);
  • a history of ischaemic heart disease
  • whether there have been any previous investigations for chest pain.

Key questions to ask include:

  • chest pain or in other areas (such as, the jaw, arms or back) lasting 15-minutes or longer
  • associated symptoms (particularly nausea and vomiting, profuse sweating, difficulty breathing)
  • chest pain associated with cardiovascular instability (such as low blood pressure, tachycardia)
  • chest pain occurring frequently with little or no exertion, with episodes of chest pain occurring often longer than 15-minutes
  • Note that it was previously considered a sign of cardiac chest pain if there was a response to GTN – this has since been proven to be a false positive as a positive response to nitrates can occur in non-cardiac chest pain. It should therefore not be used as a discerning factor.

Reassuring features in this case include: the pain was relieved with simple analgesia (paracetamol); the nature of the pain with tenderness on palpation; cause consistent with musculoskeletal chest pain; entirely normal haemodynamic parameters; and the age and previous health of the patient. However, as the activity described by the patient could potentially cause a dissection, it is best to carry out basic investigations such as the blood pressure in both arms (check for a difference of 20mmHg or more in the systolic pressure) and for a widened mediastinum. If either of these are present, consider a computer tomography of the aorta to exclude aortic dissection.[/vc_column_text][/vc_accordion_tab][vc_accordion_tab title=”Specimen case presentation”][vc_column_text]”This young man has presented with central chest pain while exerting himself playing tennis. The symptoms are not in keeping with a life threatening condition, along with the physical signs of pain on palpation and movement, however, to ensure there is not, I would like to carry out a 12-lead electrocardiogram for ischaemia, plain chest radiograph for a widened mediastinum and any evidence of a pneumothorax and baseline blood tests including a troponin.”[/vc_column_text][/vc_accordion_tab][/vc_accordion][/vc_column][/vc_row]