Embedded Files
FM&PH – Chest pain
In module Family Medicine and Public Health
Mr Charlie Walker is a 63 year old gentleman who presents to an emergency GP appointment with an 8 hour history of stomach and chest pain.
MAIN CASE
Guidance and Resources – Chest pain MED 35
Case Introduction – Chest pain MED 35
Further Case Information – Chest pain MED 35
Background Science – Chest pain MED 35
Case Conclusion – Chest pain MED 35
Formative Assessment – Chest pain MED 35
CASE COMPONENT
Guidance and Resources – Chest pain MED 35
In case FM&PH – Chest pain
Learning Resources
Here is a list of useful links for your information or reminders about what you have already covered in relation to this case. They are listed here for ease of reference and you may wish to return to this page after you’ve worked through the case, but review of any of this material before you start the case is not compulsory.
You will be directed to specific information contained within some of these links as you work through this case, but can come back to this list if you want further information or are interested to know more.
Recommended Reading
· Prescribing NSAIDs
· Chest pain Case Year 4
· Diabetes Case Year 4
· Chronic Kidney Disease Year 4
· Liver, Biliary and Pancreatic disease Year 4
· GMC Guidance about Chaperones
Additional Resources
· Diagnosis of Type 2 diabetes
· Managing challenging interactions with patients (Must be viewed using the University wifi or VPN)
CASE COMPONENT
Case Introduction – Chest pain MED
In case FM&PH – Chest pain
It is 9am Friday morning and you have just arrived at the GP Surgery. Your GP Tutor, Dr Mitchell, has just started to tell you that she did not have a good night’s sleep due to her son’s teething when the receptionist asks her to see Mr Walker as an emergency extra. He has come in to the surgery without an appointment, saying he has chest pain and needs to see a doctor this morning.
Mr Charlie Walker is a 63-year-old council worker. Dr Mitchell tells you that she knows him well as he comes to the surgery often. He was seen just 3 days ago by a colleague for a swollen foot and ankle and diagnosed with gout.
Dr Mitchell suggests that you ‘hot seat’ the consultation.
You look through Mr Walker’s notes before you call him in.
· Problems list: anxiety, osteoarthritis, cholesterol, QRISK2 22%, BMI 33
· Repeat Medications: Sertraline 100mg, co-codamol 30/500mg, atorvastatin 20mg
· Allergies: Nil
· Investigations: March 2017 FBC normal, eGFR 69, HbA1c 39, LFTs normal, LDL cholesterol 5.5, HDL 1.8
· Alcohol intake: less than 14U/week
Notes from 2 days ago
Problem: Gout
Acute history of swelling L foot/ankle 1/7. Red and painful. Previous history of swollen big toe on that foot 2 months ago treated as possible gout but didn’t come back for bloods. Patient says feels same. Responded to short course naproxen.
Examination: Afebrile 36.6, BP 138/78. Left 1st MTPJ swollen, L ankle mild erythema and swelling. Normal range of movement. Red, but not hot, very tender. No other joints involved; no swelling or tenderness of calf.
Diagnosis: Gout, recurrent.
Comment: NSAID, PPI cover and bloods.
Swollen ankle concept map
This interactive component outlines the assessment the doctor might do to work out what is more or less likely when someone presents with a swollen ankle.
Work through the different options, clicking yes or no, and see how different symptoms and signs can allow you to work out the most likely working diagnoses, or inform next best investigation or management plan:
In Week 1, you came across a case of Ali with his back pain, who was given ibuprofen, a non-steroidal anti-inflammatory drug (NSAID). In this case, this medication might be more risky as Mr Walker takes an SSRI which itself can increase the risk of bleeding, particularly within the GI tract when combined with an NSAID. In this case the GP decided to issue Mr Walker with omeprazole, a proton pump inhibitor which reduces acid in the stomach. The risk of bleeding should still be communicated to the patient; he should be advised not to suddenly stop his antidepressant, but to report any indigestion or stomach upset.
CASE COMPONENT
Further Case Information – Chest pain MED 35
In case FM&PH – Chest pain
You call Mr Walker in. He says he has been up through the night with pain in his stomach and chest.
“It must be that naproxen, the doctor did warn me. He said he gave me something to protect my stomach but then I didn’t seem to have it on the prescription. He’s a terrible doctor. Can you prescribe it?”
What would you do now?
· Take a more thorough history of the pain from Mr Walker with a view to developing a differential diagnosis
· You suspect gastritis secondary to the naproxen. Ask the GP to issue the missing PPI and ask Mr Walker to come back if it doesn’t help
· Take a more thorough history of the pain from Mr Walker with a view to developing a differential diagnosis
.Correct answer.
Taking a thorough history and developing a differential diagnosis forces consideration of other possibilities and avoids anchoring and increases your abilities to make the correct diagnosis.
· You suspect gastritis secondary to the naproxen. Ask the GP to issue the missing PPI and ask Mr Walker to come back if it doesn’t help
.This may turn out to be the correct action, but you may be ‘anchoring’ (this is the human tendency to rely too heavily on the first piece of information offered when making decisions). The initial information is the patient has been given naproxen for suspected gout and this has caused her to anchor on a diagnosis of gastritis due to the NSAID.
Dr Mitchell checks the medical record and sees the intended PPI has not been prescribed. She apologises to Mr Walker on behalf of the practice, and assures him that she will highlight the omission with the GP responsible. She also outlines that when any mistake is made, they consider it very carefully as a practice to see if there is anything that can be done to prevent similar happening in future. Mr Walker seems satisfied with this.
IN PRACTICE:
Ask your GP Tutor if they discuss Significant Events/errors as a practice, and if so, if you are able to attend such a meeting. All GPs will reflect on Significant Events as part of their Appraisal portfolio processes, so your GP might be willing to share one with you.
The GP asks if Mr Walker is happy for you to continue with the consultation, which he agrees to.
You start the consultation by asking the patient an open question, inviting him to tell him more about his symptoms.
Mr Walker gives you the following history:
“I have been up all night it started suddenly in my stomach and now I can feel it all around the centre here, heavy and burning. It went up into my chest. It woke me up and has been there all night. I am sure it is that naproxen. I tried my wife’s Rennie’s but they are rubbish. They didn’t help before when I had this.”
He has found nothing makes it better or worse, he didn’t feel like having breakfast, he has felt a bit nauseous. He doesn’t have any acid taste in the back of his mouth. He has felt sweaty and tired. The severity is 6/10 but getting worse.
He opened his bowels normally yesterday, he didn’t look but there was something black on the paper. He has no symptoms of shortness of breath or cough, and it doesn’t hurt when he breathes.
What is the significance of not having acid taste in the back of his mouth?
An acid taste is indicative of acid reflux, supporting a diagnosis of GORD. He does not have this symptom.
Where would you expect the pain to radiate to with pancreatitis?
To his back, or left shoulder blade.
To his back, or left shoulder blade.
What other risk factors would you want to ask about regarding pancreatitis?
Alcohol intake, history of gallstones.
What is the significance of having black stool? What could this indicate?
It could be malaena which is a sign of upper GI bleeding. If he had gastric erosions secondary to his naproxen and sertraline, he could develop an upper GI bleed.
What other symptoms might he develop with an upper GI bleed?
Haematemesis, coffee ground vomit, presyncope/syncope, and even severe abdominal pain if he developed a perforation.
Why is it important to ask about SOB or cough symptoms? What differentials are you ruling out here?
Although unlikely differentials, you need to rule out PE and pneumonia.
There are other types of common cognitive biases you should become aware of.
There are other types of common cognitive biases you should become aware of.
What else would you like to ask in the history relating to chest pain?
Think about your answers and say the questions out loud. You can then see how well you did by reminding yourself of the ‘Chest Pain’ TCD from last year.
What’s the cause of Mr Walker’s epigastric pain?
Take a look at the table below which helps you to differentiate between 3 common causes of epigastric pain and try to work out from what you know already, which you think is most likely in Mr Walker’s case?
Mr Walker has not had any high blood pressure readings and the most recent is normal.
Mr Walker has not had any high blood pressure readings and the most recent is normal.
Smoking. He does not have a history of excess alcohol intake or gallstones.
Examination
Dr Mitchell invites Mr Walker for an examination, and outlines that a digital rectal examination may be useful. She outlines what this is and offers a chaperone. Mr Walker consents to the examination in the presence of a chaperone, and yourself.
A DRE could be indicated in this case to exclude malaena or fresh blood – which would be a sign of a GI bleed. It is important before any examination, but particularly with an intimate examination, that a chaperone is offered. Naproxen can cause gastric erosions which can bleed. Mr Walker has reported black stool on wiping. He is tachycardic, sweaty and hypotensive which would support a GI bleed, as well as a differential diagnosis of a myocardial infarction.
On examination, Mr Walker is afebrile, T 36.4. He is not jaundiced. Dr Mitchell examines his chest and finds a regular heart rate, with no added sounds but an increased rate of 110. His BP is 90/68. She finds he has tenderness over the epigastrium, but no rebound or guarding. His bowel sounds are present. She discovers tar black stool on her glove
IN PRACTICE:
Find out in your surgery how you would get help in an emergency situation.Find out if your practice has facilities to do ECGs, and if you can help with doing an ECG for a patient.
CASE COMPONENT
Background Science – Chest pain MED 35
In case FM&PH – Chest pain
You have covered several of the conditions in this case previously. Look back at the resources on One Med Learn for the background science:
· Year 4 Chest Pain Case
· Cardiovascular Week: Pulmonary Embolus
· Bioscience Resources for GORD
· Liver, Biliary and Pancreatic disease
CASE COMPONENT
Case Conclusion – Chest pain MED 35
In case FM&PH – Chest pain
Dr Mitchell agrees with your opinion that the likely diagnosis is a GI bleed, possibly secondary to the NSAID and made more likely due to concomitant sertraline. As Mr Walker is tachycardic and hypotensive Dr Mitchell suggests that the patient should be admitted by ambulance to hospital. She discusses her concerns with Mr Walker, who agrees with this management plan.
An ambulance is arranged whilst Dr Mitchell refers Mr Walker through to the hospital receiving team. Dr Mitchell prepares a letter for admission to include Mr Walker’s medical history and medications, and gives the Paramedics a verbal summary when they arrive and take over the care of the patient.
A week later, Dr Mitchell shows you Mr Walker’s discharge summary:
Discharge summary
St Elsewhere’s Hospital
Otherstown
Tel: 0555 123 4567DISCHARGE SUMMARYDate of discharge: 01/09/2017
Consultant at discharge: Mr BloggsDiagnosis: Gastric erosion secondary to naproxen; episode of melaena on the ward. Out patient OGD. Hb stable.Actions for GP: Please check FBC and review ferrous sulphate
Medications
· Omeprazole 20mg bd
· Atorvastatin 20mg on
· Ferrous sulphate 200mg tds
The following week, Mr Walker comes back to see Dr Mitchell when you are with her. He thanks you for admitting him as he didn’t realise it was so serious. He is really worried because his stool has been dark again and he is feeling slightly sick with stomach pains.
Dr Mitchell takes time to explore these concerns, and takes a full history around the symptoms. Mr Walker describes his stools as ‘gritty’, and not sticky. There are no associated symptoms. The stomach pains are crampy in nature, and relieved with defaecation. All these symptoms started the day after starting his iron tablets.
Dr Mitchell reassures Mr Walker that ferrous sulphate can cause stomach upset, cramps, dark grittiness of the stools and altered bowel habit, either towards constipation or diarrhoea. Mr Walker feels very reassured, and is happy to persevere with the iron tablets. He informs Dr Mitchell that he has an appointment in 2 weeks for a ‘camera test’ and that this has been fully explained to him.
Dr Mitchell advises him that his new medications should prevent any further bleeding and symptoms like he had last week, but to get in touch with the GP surgery or NHS111 if he develops any further chest pains, stick tarry black motions or any new symptoms.
She advises him how to take his medications as prescribed until further review. She advises him not to take ibuprofen or similar anti-inflammatories over the counter from now on, without first discussing it with a medical professional. She suggests repeating some blood tests and making a review appointment 1 month, at which stage they can review the medications and should have the results of the upper GI endoscopy.
Finally, Dr Mitchell adds ‘Intolerance to NSAID: Gastric erosion’ to Mr Walkers medical record within the problem list. This will flag if naproxen or similar NSAID medication is prescribed in future and is an example of how the GP uses the computer to help ensure patient safety.
Formative Assessment – Chest pain
Ferrous sulphate can cause which of the following (Select ALL that apply)
· Nausea and vomiting
· Stomach cramps
· Constipation
· Diarrhoea
· Dark stools
· Nausea and vomiting
.Correct answer.
· Stomach cramps
.Correct answer.
· Constipation
.Correct answer.
· Diarrhoea
.Correct answer.
· Dark stools
.Correct answer.
A chaperone should be offered:
· For all examinations which the patient may consider intimate
· Only you are a different gender to the patient
· Only if there isn’t a relative or friend of the patient available
· For all examinations which the patient may consider intimate
.Correct answer.
For all intimate examinations, particularly breast, genitalia and rectum, though for some patients any examination where it is necessary to touch or get close to the patient may be considered intimate.
· Only you are a different gender to the patient
.Offering a chaperone should happen regardless of whether or not you are the same gender as the patient
· Only if there isn’t a relative or friend of the patient available
.A relative or friend of the patient is not an impartial observer, so would not usually be a suitable chaperone
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