Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a Foundation Year 1 Doctor working in the Emergency Department. Your next patient is a 42-year-old woman (Alexander Great) presenting with abdominal pain. Please take a history and perform an appropriate examination.
Patient History:
Alexander Great, a 42-year-old retired hairdresser.
This morning at around 3am, you woke up from having tummy pain. Described as a sharp/burning sensation that started at the bottom chest centrally and radiated up to the neck. It is intermittent and lasts for a few seconds. Pain score: 5/10. You are known to have angina, and so you took a GTN spray, but it didn't help. You feel a bit nauseous but no vomiting; you had some retching (and a bad taste in the back of the throat). Pain tends to be worsened or triggered when you try to go back to bed and lay flat.
If asked specifically, you remember having quite a big family meal when your friend came to visit the night before.
No weight loss. No tiredness. No erosion in teeth. No bad-smelling mouth. No lump in the throat. No bloating. No nocturnal cough. No hoarse voice. Bowels working normally with no bloody stool. No breathing difficulty. No dysphagia. No LOC. No dizziness. No palpitation. No obvious chest pain.
Ideas, Concerns, Expectations:
You are not sure what is going on. You are worried that you had a heart attack and may die because of this since it is quite close to the chest. You want to be seen by a cardiologist and have some medications to help prevent having this pain again. You want to live!
Past Medical History:
Hypertension
Stable angina - well-controlled
Obesity
Chronic Lower Back Pain
Drug History:
Amlodipine, GTN spray PRN, Atovastatin, ibuprofen
NKDA
Family History:
Type 2 DM (Dad, age 44)
Colon Cancer (Dad, age 65)
Social History:
Smoker – 10 cigarettes/day for 20 + years
Drink a small glass of gin and tonic every night
Hairdresser
Drink 2 cups of coffee a day.
Examination Findings:
The patient is alert + comfortable at rest, with no signs of breathing difficulties.
No clinical signs of anaemia.
Some mild discomfort palpating the epigastric region.
Abdominal examination is otherwise normal.
PR exam is normal - no melena or blood in the stool.
Differentials:
GORD
Gastritis
Peptic ulcer
Hiatus Hernia
Oesophagitis / Oesophageal spasm
To rule out cardiovascular causes: Stable Angina / ACS / AAA
Investigations:
Bedside:
Observations
ECG – rule out cardiac cause
Bloods:
FBC, CRP, U&Es, LFTs, Bone Profile, Troponin (if suspecting cardiac cause)
Imaging:
CXR/AXR (?Hiatus hernia)
Special Tests:
Consider serology/ urea breath test/ stool antigen, rapid urease test (H-pylori testing - ensure not taken PPI 2 weeks prior to testing)
Barium swallow - assess dynamics, assess motility disorder, assess for hiatus hernia
Oesophageal pH monitoring / Manometry - Assess for motility & regurgitative Disorders
Consider OGD (Savary-Miller grading/ Los Angeles Classification) - allows direct visualisation and biopsy for histology.
Data Interpretation: