MED 1022 WEEK 12 – Theme IV Clinical Skills

Clinical Reasoning

CASE 1

History (12 minutes)

Name: Tatiana Russel

Age: 70

Occupation: Retired social worker

Presenting complaint: Chest pain

History of the presenting complaint: For the past 4 months, I’ve been having chest pain.

Give the following information only if the student taking the history specifically asks for them.

The pain feels like a pressure under my breast bone. It is brought up by exertion (e.g. on
climbing the stairs, I also cannot make it up the slight incline outside my house) and is
relieved by rest. The pain in only in my chest and it doesn’t go anywhere else. I rate it as 4 -
5 out of ten. It is associated with dyspnoea and sometimes a feeling of light-headedness. I
believe it’s my heart. My father died of a heart attack when he was my age.

Impact: I can’t do much anymore

Concerns: Worried about having a problem in the heart or the brain

Expectations: I just want to know what’s going on

Cardiovascular system review

Chest pain: as above

Dyspnoea: Yes. Only on exertion

Orthopnoea: No. I sleep with one pillow

Paroxysmal Nocturnal Dyspnoea: No

Fatigue: I sometimes feel tired/occasionally

Syncope: light-headedness on exertion – I also had an episode of passing out while walking
last week. I’m lucky my son was with me. He said it lasted for a few minutes only. I
remember feeling light-headed before passing out. No injuries

Ankle oedema: No

Palpitations: No

Intermittent claudication: No
MSK system review: Answer NO to all

Neurological system review: Answer No to All apart from syncope

Past Medical History:

I had my appendix removed at the age of 30

Hypertension for the past 5 years

No history of hyperlipedemia or DM

Immunisations: Flu vaccine 6 months back

Family history:

Father died of a heart attack at the age of 60

Mother had a stroke at the age of 85 and died a year later

I have one brother (72) – He has HT

Grand parents – they both passed away on plane crash before I was born

DRUGS history:

Prescribed medications: Is on Perindopril tablets 5mg once/day

Non-smoker - Never smoked

Drink 2 small glasses of red wine every evening with dinner

No illicit drugs, No allergies, No herbal medication

Social history

I live with my husband Andrew (72 yr old) in a small house near the city. We have 4 children
(all married) and 6 grand-children. One of my children is a drug addict and I always worry
about him and his family. He is married and he has 3 young children (2 – 4 and 5 yo).

Diet: We eat healthy food.

Exercise: Used to walk for an hour every day. Not anymore for the last 4 months. Can only
walk for 10 minutes/day

Spirituality: None

Social support: Family, neighbours and friends

Clinical reasoning

Summarise the history to your tutor/or peer

Discuss with your tutor the patient’s risk factors for CVD

What is your DDX?

Perform a complete examination of the cardiovascular system (12 minutes)

Check the patient’s Blood Pressure (4 minutes)

Discuss with your tutor what would you be looking for on physical examination of this patient

Discuss the most likely diagnosis

What Inx would you consider?