| | 22 Case 22 scenario (chest pain)
Doorway information about patient
The patient is a 55-year-old man who comes to the emergency department due to chest pain
Vital signs
. Temperature : 37.1 C (98.7F)
. Blood pressure : 130/80 mmHg
. Pulse : 78 /min
. Respirations : 20/min
Clinical images
ECG is shown in the image : S-T segment lowered
Basic differential diagnosis
. Miocardio infarction
. Unstable angina
. Pulmonary embolism
. Costochrondritis
. Pleuritis
. Pericarditis
. Aortic dissection
. Gastroesophageal reflux
. Esophageal; perforation
—————
Case 22 sim.pt. instruction
If the doctor asks you about anything other than these , just say “ no ,” or provide an answer that a normal patient might give.
You are a 55-year-old man who comes to the emergency department with chest pain.
History of present illness
. The pain came on suddenly and has progressively worsened
. Pain located in substernal area with no radiation
. “Tight , squeezing “ sensation with 8-9/10 severity
. Pain is worse when walking and moving around
. Associated symptoms:
- Nausea
- 1episode of vomiting
- Sweating
- Mild shortness of breath
Review of systems
. No fever , cough , headache . abdominal pain , diarrhea , constipation , recent trauma, appetite changes weight loss , or urinary problems
Past medical history
. High blood pressure for 20 years
. Diabetes for 5 years
. Cholesterol tested a year ago was 280 ( you are trying to control your cholesterol who diet but not eat a lot of fast food)
. No surgires
. Medications : lisinopril , metformin
. No allergies
. Father died at age 60 of heat attack ; mother tis living and ad stroke at age 65 ; brother had a heart attack at age 58
. Occupation : lawyer
. Married , live with wife
. Tobacco : 1 pack a day for the past 30 years
. Alcohol : 1 glass of wine a day for past 20 years
. Recreational drugs : No
Physical examination
Physical examination
Neck :
. supple without JVD or lymphadenopathy
. No thyromgaly
Lungs :
. Clear to auscultation bilaterally
. No reproducible chest pain with palpation
Heart :
. Regular rate and rhythm
. No murmurs , gallops , or rubs
Review of system
You have non of the following:
. Fever
. Cough
. Headache
. Abdominal pain
. Diarrhea
. Constipation
. Recent trauma
. Appetite changes
. Weight loss
. Urinary problems
—————
Case 22 sim. pt. checklist
Following the encounter , check which of the following items were performed by the examinee
History of present illness/ review of systems
. Asked about the location and radiation of pain
. Asked about the intensity of pain
. Asked about the quality of pain
. Asked about the origin and duration of pain
. Asked about the course of pain over time
. Asked about any aggravating or relieving factors
. Asked about associated symptoms , especially :
- Nausea and vomiting
- Sweating
- Fever
- Coughing
- Shortness of breath
- Palpitations
- Syncope and dizziness
Past medical /family/social history
. Asked about similar episodes in the past
. Asked about past ,medical issue (especially high blood pressure , heart problems , diabetes , heart burn/reflux), hospitalizations , and surgeries
. Asked about current medications and medication allergies
. Asked about family health
. Asked about tobacco , alcohol , and recreational drug use
. Asked about occupation and stress in life
. Asked about cholesterol level (if known)
Examination
. Washed heads before examination
. Examined without gown , not through gown
. Examined carotid artery and jugular viens
. Examined heart (inspection , palpation , auscultation)
. Auscultated the lungs
. Examined peripheral pulse and edema
. Examined abdomen
Counseling
. Explained the physical findings and possible diagnosis
. Discussed ECG result
. Explained further workup
. Discussed lifestyle modifications ( especially quitting smoking and moderate alcohol intake).
Communication skills and professional conduct
. Knocked before entering the room
. Introduced self and greeted you warmly
. Used your name to address you
. Paid attention to what you said and maintained good eye contact
. Asked opened questions
. Asked non-leading questions
. Asked one question at a time
. Listened to what you said without interrupting me
. Used plain English rather than technical jargon
. Used appropriate transition sentences
. Used appropriate draping techniques
. Summarized the history and explained physical findings
. Expressed empathy and gave appropriate reassurances
. Asked whether you have any concerns/questions
Differential diagnosis
. Myocardial infarction
. Unstable angina
. Pulmonary embolism
. Aortic dissection
. Gastroesphageal reflux
Diagnostic study/studies
. Complete blood count
. Cardiac markers (eg, troponin)
. Electrolytes . blood urea nitrogen, creating , glucose
. Chest x-ray
. Echocardiogram
—————
Case 22 clinical summary
Clinical Skills Evaluation
Case Patient Note
The following represents a typical note for this patient encounter . the detail may vary depending on the information given by the simulated patient.
History : Describe the history you just obtained form this patient . Include only information (Pertinent positives and negatives) relevant to this patient’s problem(s).
. 55-yo man with 2 hours of chest pain described as substernal tightness and pressure and increased with movement and walking ; pain of 8-9 lb on a scale of 10 , no radiation.
. Associated nausea , vomiting , sweating , and shortness of breath
ROS : No fever , cough , headache , abdominal pain , diarrhea , constipation , recent trauma, appetite change , weight loss , or urinary problems
PMHx : HTN , diabetes , hight cholesterol
PSHx : None
Meds : lisinpril, metformin
Allergies : None
FHx: Fateghr died at age 60 of heat attack , motor had a stroke at age 65 , and mother had a heart attack at age 58
SHx: 1 PPF smoker for past 30 years , 1 glass of wine/day for past 20 years
Physical examinations : Describe any positive and negative findings relevant to this patient’s problem(s) . be careful to include only those parts of the examination performed in this encounter.
. Vital signs ; Temperature ,. 37.1”C (98.8F) : blood pressure , 130/80 mmHg; pulse , 78/min; and respirations , 20/min
. Neck ; Supple without JVD or lymphadenopathy , no thyromegaly
. Lungs ; Clear to auscultation bilaterally , no reproducible chest pain to palpation
. Heart : RRR without murmurs , gallops , or rubs
Data interpretation : Based on what you have learned from the history and physical examination, list up to 3 diagnosis that might explain this patient’s complaint(s) . List your diagnoses from most to least likely . For some cases , fewer than 3 diagnosis will be appropriate . the , enter the positive and negative findings form the history and the physical examination (if present) that support each diagnosis . Finally , list initial diagnostic (if any) you would order for each listed diagnosis (eg,restricted physical examination maneuvers, laboratory tests , imaging ECG , etc).
Diagnosis #1 : Acute contrary syndrome
History finding(s)
. Substernal chest pain
. History of multiple cardiac risk factors
. Nausea , vomiting , diaphoreses
Physical examination finding(s)
. No reproducible chest pain to palpation
Diagnosis #2 : Aortic dissection
History finding(s)
. History of hypertension
. substernal pain
. Sudden-onset symptoms
Physical examination finding(s)
. No reproducible chest pain to palpation
Diagnosis #3 : Pulmonary embolism
History finding(s)
. Sudden -onset chest pain
. Shortness of breath
Physical examination finding(s)
. No reproducible chest pain to palpation
Diagnostic studies
. ECG shows ST depressions in V2-V5
. Chest x-ray
. Cardiac enzymes
. Echocardiogram
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2018/09/13 07:49am 
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