Histories

Cardiovascular History:Chest Pain

Respiratory History:Productive Cough

GI History:Abdominal Pain

GI History:Diarrhoea

Neurological History:Headache

Intermittent Claudication

Back Pain History

Haematological History

Breast History

Sexual History:Vaginal Discharge

Station 1 CARDIOVASCULAR HISTORY: CHEST PAIN

Candidate Briefing: Mrs. Jones is a 60 year-old lady who presented with a two-hour history of central chest pain, shortness of breath and sweating. Please take a history from Mrs. Jones and then present your findings.

Patient Briefing: You are 60 years old and your name is Mrs. Jones. You have presented to the emergency department today with a two-hour history of central chest pain. The junior doctor has come to take a history from you.

The chest pain is central and came on gradually 2 hours ago. The pain is dull in character and radiates to your left arm. The pain came on whilst you were watching television and has not yet gone away. At the moment there is nothing that is making the pain worse although you do not feel like moving. You took some paracetamol earlier but this did not relieve the pain. The pain is eight out of ten in severity.

In addition to the chest pain you are also feeling short of breath and sweaty; both of which have come on over a similar time period to the chest pain. You have no nausea, palpitations, presyncope, syncope, ankle swelling, cough, sputum or haemoptysis.

You are known to have unstable angina and recently you have noticed that your angina pain is coming on with less and less exertion and it has been associated with breathlessness. You did not seek any help for the chest pain and hoped that it would get better again.

You also have high blood pressure and diabetes. You have never had a heart attack, a mini stroke, stroke or problems with circulation in your legs. You have never been told you have high cholesterol.

You take amlodipine 5mg and aspirin 75mg once a day and your diabetes is diet controlled. You have no drug allergies. Your father died of a heart attack aged 50 and your mother has type 2 diabetes. You currently smoke 20 cigarettes a day and have done for the last 40 years. You drink 2-3 glasses of wine every evening. You eat a lot of takeaways and do not eat much fruit or vegetables. You do not do any regular exercise. You are a retired secretary.

If asked, your main concern is that you are having a heart attack and are worried that you are going to die. You are hoping that the doctor will be able to reassure you.

Mark Scheme for Examiner

Introduction

Clean hands, introduce self, confirm patient identity and gain consent for history taking

Chest Pain History

Site

Onset

Character

Radiation

Timing and duration

Exacerbating factors

Relieving factors

Severity

Previous episodes of chest pain

Associated Symptoms / Systemic Enquiry

Shortness of breath

Autonomic symptoms (nausea, vomiting, sweating)

Palpitations

Presyncope and syncope

Ankle and calf swelling

Cough and sputum production

Haemoptysis

Past Medical History

Previous chest pain. Angina or myocardial infarction

Previous interventions (angiography/CABG)

Stroke or peripheral vascular disease

Diabetes mellitus

Hypertension

High cholesterol

Drug History

Drug and allergy history

Family History

Family history of heart disease (including age of any significant events e.g. myocardial infarction)

Social History

Smoking status. Duration and quantity of cigarettes smoked

Alcohol intake, lifestyle (diet, exercise) and occupation

Finishing the Consultation

Elicit patient concerns

Summarise history back to patient

Thank patient and close consultation

General Points

Polite to patient

Maintain good eye contact

Appropriate use of open and closed questions

Presentation of case

Questions And Answers for Candidate

With a convincing history, what ECG changes would support immediate percutaneous coronary intervention?

• With a convincing history, I would be concerned by ST elevation of 1mm or more in consecutive limb leads (I, II, III, aVF, aVL, aVR); or ST elevation of 2mm or more in consecutive chest leads, or new onset left bundle branch block (though some centres are now using ST elevation of 1mm in the limb leads as the criteria for PCI)

What artery supplies the sinoatrial tissue of the heart?

• The right coronary artery supplies the sinoatrial nodal artery 60% of the time, the remaining 40% of the time it is supplied by the left circumflex artery

What areas of the heart are supplied by the left anterior descending artery?

• The left anterior descending artery supplies the anterolateral myocardium, the apex and the interventricular septum. Typically it supplies up to 55% of the left ventricle

Additional Questions to Consider

1 // What is the differential diagnosis of chest pain?

2 // How might you differentiate the pain of an MI from pericarditis on history?

3 // What are the immediate and later complications of myocardial infarction?

4 // What is the role of primary angioplasty in acute myocardial infarction?

5 // What advice would you give this patient on discharge?

6 // According to current recommendations, what drugs should be on a patient's discharge letter post acute MI?

7 // What groups of people are at higher risk of a silent myocardial infarction?

Patient Briefing: You are 60 years old and you are called Mr. Gordon. You have presented to hospital with a three-day history of a productive cough. You have been finding it increasingly difficult to sleep and get around your house because of breathlessness.

Your cough started three days ago and has been getting gradually worse. You are now having severe coughing bouts eight times a day and producing sputum each time. You estimate that you are producing two cupfuls of sputum a day. Your sputum is yellow / green in colour and is thick in consistency. You have not coughed up any blood.

You have been feeling increasingly short of breath over the last three days which came on relatively quickly. You are now breathless at rest and...