CARDIOLOGY

Identify a patient to be seen with chest pain that is suitable and has consented to being seen. Before going to see the patient, write down as many causes of chest pain as you can. Remember to consider non-cardiorespiratory causes.

Highlight three of the most serious causes and consider the key questions to ask to rule-in or rule-out this diagnosis.

Take a focused history from a patient with chest pain to include past medical history, drug history, family history and social history, remember to ask about key risk factors and questions to differentiate between key causes you have identified.

Perform a focused cardiovascular examination on the patient.

Document your findings in a systematic manner. You may want to use a local clerking proforma or have a look at this useful summary from Geeky Medics.

Using your initial list of differential diagnoses for chest pain, which of these do you think are most likely for the patient you have seen (try to choose no more than three). What are they key findings from history and examination that support your choices?

Are there any other, serious causes you feel should be ruled out? Why?

Consider what are the key investigations that should be performed in a patient presenting to hospital with chest pain? What are you expecting these to show in this patient?

Review the patient’s notes and find any ECGs that have been performed. Using a systematic approach, see if you can identify any abnormalities. If the patient has had more than one ECG this admission, compare the ECGs to each other and if possible, to an ECG performed prior to this admission. Can you identify any differences (dynamic changes) between them?

Not all changes between ECGs are concerning. Can you think of any reasons why two ECGs done in the same patient may show differences that are not concerning? Are there any ways we can mitigate this?

Consider:

• What are the key ECG findings in acute coronary syndrome?

• Which are the most concerning findings and why?

Find the local acute coronary syndrome guideline for your hospital. Using this, review the patients blood results, looking for the troponin result. Was this raised?

Using the guideline, interpret the patient’s troponin result. What is the most likely diagnosis at this stage?

According to the guideline, what is the most appropriate medical management for a patient presenting with acute coronary syndrome?

Have a go at prescribing these on a mock drug chart if available.

Consider:

• What are the indications for primary percutaneous coronary intervention?

• When and how should this be done?

• What does it involve?

• What are the risks?

If possible, see if you can observe a coronary angiography and stenting to clarify your answers and further your understanding of the procedure. You could practice explaining this to a colleague as if they were a patient.