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Chest Pain History #3

PATIENT INFORMATION

You are working as an intern in a metropolitan ED. You have been asked to assess Bertha Jones, a 51-year-old female who has presented with chest pain.

CANDIDATE INSTRUCTIONS

You will have 8 minutes to perform the following:

  1. Take a history from Bertha based on her presenting complaint. (5 minutes)
  2. Interpret investigation results. (1 minute)
  3. Outline and justify your provisional diagnosis using relevant risk factors. (2 minutes)

TASK 1 – HISTORY (5 MINUTES)

Introduction

Introduces self

Hand hygiene

Confirms patient identity

  • Not of Aboriginal or Torres Strait Islander origin

Opening statement

“Doctor, my chest really hurts!”

HOPC

  • Site: Central chest pain, if asked nil radiation
  • Quality: Sharp and stabbing
  • Severity: 10/10 – “it woke me from my sleep!”
  • Time course: Started 1 hour ago
    • Onset: Sudden
    • Pattern: Constant
    • Progression: Staying the same
    • Previous episodes: Nil
  • Exacerbating/relieving factors: Worse when breathing/coughing/sneezing

Context/associated features

  • 3 marks for asking about features from ≥3 systems, 2 marks for 2, etc.
  • 1 mark for excluding red flag conditions
  • 1 mark for asking about risk factors of PE

Symptoms in BOLD indicate positive answers, other answers are suggestions of what to ask.

Context:

  • Recent travel (flew back from UK 4 days ago to see family)
  • Current smoker
  • On HRT – menopause diagnosed last year
  • Nil recent illness/sick contacts
  • Nil trauma
  • Nil PMHx CVD/resp/Ca/clotting
  • Nil recent surgeries or obesity

Associated features:

  • Resp
    • DVT/PE: SOB, palpitations (regular); 3/7 painful tender red swollen right leg
    • Pneumothorax: nil recent trauma/COPD/connective tissue disease
    • Pneumonia/LRTI: nil cough/fever/sweats, nil sick contacts
    • Lung Ca: nil haemoptysis, weight loss, fatigue
    • TB: born in the UK, nil recent travel
  • Cardiovascular
    • AMI: nil crushing chest pain, radiation to neck/jaw/shoulder, N/V
    • Pericarditis: nil preceding URTI, pain relieved on leaning forward
    • Aortic dissection: nil radiation to back, syncope, connective tissue disease/HTN
  • GI
    • Nil N/V, changes to bowels
  • MSK
    • Fracture/strain: nil trauma
    • Costochondritis: nil pain on palpation
  • Derm
    • Shingles: nil PMHx chicken pox, nil dermatomal rash (can appear after pain)
  • Psych
    • Anxiety: nil psychiatric Hx, anxious mood

Past medical history

  • Menopause – diagnosed last year
  • Osteoarthritis – in both knees
  • Osteoporosis

Medications

  • Prescription:
    • Oestradiol 2mg + Dydrogesterone 10mg (Femoston 2/10) PO daily
    • Paracetamol modified release 1.33g PO BD
    • Naproxen 500mg PO BD
    • Pantoprazole 20mg PO daily
    • Denosumab 60mg IM 6 monthly
  • Nil OTC or supplements

Allergies

  • Penicillin – anaphylaxis

Family history

  • Mum has osteoporosis
  • Nil other, including nil haematological

Social history

  • Retired accountant
  • Lives with husband, iADLs
  • Strong social network – attends weekly book club
  • Current smoker – 10 cigs/day for 20 yrs
  • Nil EtOH/recreational drug use
  • Diet: balanced and healthy
  • Exercise: relatively sedentary due to osteoarthritis (limited mobility)

TASK 2 – ECG INTERPRETATION (1 MINUTE)

An ECG was conducted on Bertha. Please interpret the salient findings of the ECG.

Please show the candidate the ECG on the next page.

  • Patient details: ECG of Mrs Bertha Jones, age 51, performed at 10:11pm on [today’s date]
  • Sinus tachycardia
  • Remainder NAD

TASK 3 – DIFFERENTIAL DIAGNOSIS + JUSTIFICATION (2 MINUTES)

Outline and justify your provisional diagnosis using relevant risk factors.

  • Diagnosis 1 mark
  • 2 marks for mentioning ≥2 of Hx, Ix or risk factors
  • Pulmonary embolism
    • Sudden onset pleuritic chest pain and dyspnoea, on b/g 3/7 clinical right-sided DVT and multiple risk factors (recent long-haul flight, limited mobility, HRT, smoking)
    • Sinus tachycardia on ECG (most common PE finding)
Total:

ECG interpretation

ECG of Mrs Bertha Jones, age 51, performed at 10:11pm.

NOTES

Pulmonary embolism (PE) is an important, preventable cause of morbidity and mortality that must always be considered in a presentation of chest pain or dyspnoea. The most common ECG finding in PE is sinus tachycardia. Other signs include S1Q3T3, and evidence of right heart strain (RBBB, RAD, T wave inversions V1-4 +/- leads II, III, aVF).

  • Symptoms: sudden onset dyspnoea, pleuritic chest pain, syncope, haemoptysis
  • Signs: tachypnoea, tachycardia, hypotension, Homan’s sign (DVT)
  • Risk factors: PMHx/FHx clotting disorders/malignancy (pro-inflammatory state)/VTE, HRT/COCP, obesity (pro-inflammatory, also compression of iliacs), pregnancy, surgery (especially orthopaedic), immobilisation (travel, mobility injuries, hospital stay), trauma, smoking, old age.

Work up

  • Clinical suspicion of a VTE should be followed up with Wells’ Criteria, which provides an estimated pre-test probability (NB: PERC is used to rule out a PE. If there is a low pre-test probability and a PERC of 0, no further investigations are required for PE).

High risk patients should be further investigated with:

  • Imaging, e.g. CTPA or V/Q scan
  • Consider compression U/S of legs if clinical suggestion of DVT
  • ?D-dimer in high clinical risk, as effective in ruling out VTE but not at ruling one in (i.e. sensitive but not specific)
    • Can also be high in pregnancy, trauma, recent surgery, heart disease, infection and even in elderly people

Management involves:

  • Anticoagulation (e.g. DOACs, warfarin, LMWH): 6 months for unprovoked, 3 months for provoked
  • Risk factor optimisation
  • Other (case-by-case basis):
    • Thrombolysis – only for massive PE, where benefit to unstable patient is greater than the risk of bleeding
    • Procedural intervention (e.g. VIC filter)
    • Further investigation if recurrent/atypical, e.g. thrombophilia testing

REFERENCES