OSCE CHES) PAIN = (AML) Mr Jones, a 47 vear old man, presents to the emergency department with epigastric pain. Please take a history after which I shall ask you for vour differential diagnosis. I will then ask you some questions about managing this patient. * Introduce self + Pain questions * where is the pain (upper epigastrium) * quality of pain (like a tight band. like someone sitting on me) + duvation (hegan hrs ago. lasted 1 $ hee) * severity (really bad, worst I've had) * pattern of pain (sudden onset, persistent) * radiation (to shoulder tip and down arm) * associated events (came on this moming while I was at breakfast) * relievers (GTN helped a bit) 13 * aggrevaiors (nothing) + Associated symptoms * sweating (99) ** nausea, vomiting (ves) * dizziness (yes) * apprehension (thought ] was going to die) * restlessness (couldn't sit still) * shortness of hreath (nay *+ Review of systems *CVS * Regpinaiory (vould be PE) * GIT perforated peptic ulcer etc) + Risk factors LS * family history (positive) 30 pack-year history) * hyperlipidaemia (never had it done) * diabetes (no) * hypertension (not sure) 3 13 5 Ss 3 5 wun s+ What is the most likely diagnosis? * aM 1 unstable angina, perforated peptic ulver. PE 3 +++ What investigations would you like to do’. *ECG 1 ~ ST elevation, T inversion = reciprocal ST depression Qwaves~ Troponins (cardiac specific troponin T and wupunin 1) + AST } -LDH *CXR * FBE (polymorphonuclear leucocytosis in first few days) +++ Troponins are raised. ECG changes: do these results bear out your original diagnosis? s++ How would you manage this patient? * Aspirin * Ihrombolyuc therapy + streptokinase, reteplase (rP.A), tissue plasminogen activator * Percutaneous transluminal coronary angioplasty (PTC.\) + if contra-indications to thrombolytic therapy. age 70, cardiogenic shock. * Admit to CCU. sontinuous ECG monitoring * Pain control ~ morphine. nitrogl»vctine (1efiactury pain), 6 Blockers * Oxygen * Mild Sedation (diazepam) * Beta blockers * Heparin * ACE intibiiors * measure and correct (if necessary) serum magnesium to prevent arrhythmias. TOTAL 20