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 2 doctor working in an Emergency Department. Your next patient is Marina Mason, a 45-year-old female coming in for chest pain. Please take a history and perform a relevant examination.
Patient History:
Your name is Marina Mason – but you would like to be called Mari instead. A 45-year-old female working as a product manager at Google.
An hour ago, you developed a central crushing, heavy chest pain as if someone was pressing or squeezing your chest. You have been experiencing much chest pain in the past – this time, it just felt a little different. The pain lasted longer for at least 20 minutes, and the pain radiates toward the left side of your jaw and shoulder. You rate the pain 8/10, and it happened really suddenly. At that time, you were watching television at home. You tried to take a spray your GP gave you (you can't remember the name), but it hasn't helped.
Other symptoms: You felt sweating, nauseous, breathless, the heart was racing – You thought you were about to die. You felt lightheaded.
Ideas, Concerns, Expectations:
You think this might be angina. You always have these almost at least once every month. You are worried because the pain doesn't just go away with your spray this time. You would like to find out what is going on.
Past Medical History:
Angina, Hypertension, Anxiety
Drug History:
A Spray (can’t remember the exact name), Ramipril. NKDA
Family History:
You remember your mother died of a heart condition at a young age, but you do not remember what exactly it was and when it was.
Your father has type 2 diabetes.
Social History:
Ex-smoker – smoked 20 cigarettes a day for 30 years
Drink around 1 glass of wine every night
Live alone
Work as a product manager at Google – noted been stressful lately
Examination Findings:
Observations: HR 123, bpm, Resp. rate of 29, BP 106/70 mmHg
The patient is clammy, agitated, breathing fast, and grasping his chest in pain. Heart sounds normal on auscultation, and lung fields are clear.
Differentials:
STEMI / NSTEMI
Unstable Angina
Other considerations:
Pericarditis / Myocarditis
GORD
Costochondritis
To rule out aortic dissection – tearing pain
Anxiety or panic attack
Respiratory causes: PE, pneumothorax, pneumonia
Investigations:
Observations
ECG – looking for any axis deviation, BBB, ST elevation/depression
ABG – quick assessment + due to breathlessness + for oxygen if required
Baseline bloods + specifics e.g. Troponin baseline + 6/12 hours after onset, FBC (anaemia), U&E (ACEi + electrolytes imbalance), LFTs (statins), Lipid profile, TFT, HbA1c/Glucose (risk factors for MIs), CRP (elevated in acute phase of MI)
CXR – other causes of chest pain, signs of heart failure
Echocardiography – assess functional damage
CT coronary angiogram – coronary artery disease
Data Interpretation:
Please Interpret the ECG below:
Interpretation
Management (STEMI):