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Case: Smith aged 65-years comes to ED of local hospital where you are working as HMO. Smith had chest pain for the last 2-3
hours; he tried panadol but no relief. He is a known case of HTN and DM. his current meds are coversyl 5mgdaily and metformin
500 mg BD. Smith works as accountant in local firm for last 2 years. His wife is legal adviser to same company and had two
children
Task
a. Further history: chest pain, diaphoresis and SOB; 62 pack-year smoker;
b. Examination and investigation: pale, sweaty; BMI: 29BP: 125/80, O2 sat 98%;
c. Probably diagnosis and treatment advise
History
- Ask examiner if patient is hemodynamically stable
- Can you tell more what happened? Scale of 1-10 can you rate how bad your pain is? Give Morphine until patient is
comfortable!
- Ask LOCATION of the pain. Can you please show me where it is? Radiation? What happens with change of
position/movement? What happens when you take a deep breath? Sweaty? Nausea and Vomiting? Any similar pain in
the past? Fever? Injury? Trauma? Ask about previous medical history
- Risk factors: smoker? Diet? Alcohol? Hypertension? Diabetes? hyperlipidemia? Job? Lifestyle?
Physical examination
- General appearance: unwell, sweaty and pale (I would like to shift the patient to resuscitation area give Morphine,
oxygen and nitrates provided BP is normal)
- Vital signs: normal
- Ask for ECG
Investigation
- ECG: PR prolonged (1st degree AV block)
- FBE
- BSL/urinary dipstick
- U/E
- BNP: suspecting heart failure (raised JVP and chest pain)
- Cardiac enzymes: normal
- CXR
- Angiogram within 48 hours