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cmecde 241

 Clinical Skills for OSCEs

22 Station 10 Chest pain history

Family history

Parents, siblings, and children. Ask specifically about heart disease, hypertension, and other

heritable cardiovascular risk factors.

Social history

Employment.

Housing.

Hobbies.

After taking the history

Ask the patient if there is anything else that he might add that you have forgotten to ask. This is

an excellent question to ask in clinical practice, and an even better one to ask in exams.

Thank the patient.

Summarise your findings and offer a differential diagnosis.

State that you would like to examine the patient and possibly order some investigations, in

particular:

ECG to look for or help rule out ischaemic heart disease.

Blood tests including

– troponins to look for or help rule out myocardial infarction

– D-dimers for suggestion of a DVT/pulmonary embolism (a negative result excludes the

diagnosis but a positive result does not confirm it)

– inflammatory markers such as white cell count and CRP for suggestion of pneumonia

Chest X-ray for signs of pneumonia or pneumothorax.

CTPA or V/Q scan if the history is suggestive of a pulmonary embolism.

Conditions most likely to come up in a chest pain history station

Angina:

Heavy retrosternal pain which may radiate into the neck or left arm

Brought on by effort or emotion and relieved by rest and nitrates

Risk factors for ischaemic heart disease are likely

A family history of ischaemic heart disease is likely

Myocardial infarction (MI):

Pain typically comes on over a few minutes

Pain is similar to that of angina but is typically severe, long-lasting (> 20 minutes), and

unresponsive to nitrates

Often associated with sweating, nausea, and breathlessness

Risk factors for ischaemic heart disease are likely

A family history of ischaemic heart disease is likely


Cardiovascular and respiratory medicine

Station 10 Chest pain history 23

Pleuritic pain:

Sharp, stabbing, ‘catching’ pain

May radiate to the back or shoulder

Typically aggravated by deep breathing and coughing

Can be caused by pleurisy which can occur with pneumonia, pulmonary embolus, and

pneumothorax, or by pericarditis which can occur post-MI, in viral infections, and in autoimmune

diseases

Pleural pain is localised to one side of the chest and is not position dependent

Pericardial pain is central and positional, aggravated by lying down and alleviated by sitting up or

leaning forward

Dressler’s syndrome (post-MI syndrome) is characterised by pleuritic chest pain from pericarditis

accompanied by a low-grade fever, and can occur up to three months following an MI

Pulmonary embolus:

Sharp, stabbing pain that is of sudden onset

May be associated with shortness of breath, haemoptysis, and/or pleurisy

Typically aggravated by deep breathing and coughing

May be a history of recent surgery, prolonged bed rest, or long-haul travel

Gastro-oesophageal reflux disease:

Retrosternal burning

Clear relationship with food and alcohol, but no relationship with effort

May be associated with odynophagia and nocturnal asthma

Aggravated by lying down and alleviated by sitting up and by antacids such as Gaviscon or milk

Musculoskeletal complaint e.g. costochondritis:

May be associated with a history of physical injury or unusual exertion

Pain is aggravated by movement, but is not reliably alleviated by rest

The site of the pain is tender to touch

Panic attack:

Rapid onset of severe anxiety lasting for about 20–30 minutes

Associated with chest tightness and hyperventilation

Aortic dissection:

Sudden onset, sharp, tearing pain that is maximal at the time of onset

Radiates to the back

If you cannot differentiate angina from gastro-oesophageal reflux disease and there are

no signs of ischaemia on the ECG, advise an exercise ECG stress test. If this is negative,

consider a therapeutic trial of an antacid or a nitrate.


Clinical Skills for OSCEs

24 Station 11

Cardiovascular risk assessment

Cardiovascular risk factors can usefully be divided into fixed (non-modifiable) and modifiable risk

factors. Fixed risk factorsinclude older age, male gender, family history, and a South Asian background.

Modifiable risk factors include hypertension, hyperlipidaemia, diabetes, smoking, alcohol, exercise,

and stress. Having one or more of these risk factors does not mean that a person is going to develop

cardiovascular disease, but merely that he is at increased probability of developing it. Conversely,

having no risk factors is not a guarantee that a person is not going to develop cardiovascular disease.

Before starting

Introduce yourself to the patient.

Confirm his name and date of birth.

Explain that you are going to ask him some questionsto assess hisrisk of cardiovascular disease

(coronary heart disease, cerebrovascular disease, vascular disease) and obtain consent.

Remember to be tactful in your questioning, and to respond sensitively to the patient’s

ideas, concerns and expectations (ICE).

The risk assessment

If this information has not already been provided or disclosed, find out the patient’s reason for

attending. Then note or enquire about:

Fixed risk factors

1. Age and sex.

2. Ethnic background. People from a South Asian background are at a notably higher risk of

cardiovascular disease.

3. Past cardiovascular events, e.g. MI or stroke. If the patient has a history of past cardiovascular

events, you are assessing him for secondary rather than primary prevention.

4. Family history. Ask about a family history of cardiovascular disease and risk factors for

cardiovascular disease such as hypertension, hyperlipidaemia and diabetes mellitus.

Modifiable risk factors

5. Hypertension. If hypertensive, ask about latest blood pressure measurement, time since first

diagnosis, and any medication being taken.

6. Hyperlipidaemia. If hyperlipidaemic, ask about latest serum cholesterol level, time since first

diagnosis, and any medication being taken.

7. Diabetes mellitus. If diabetic, ask about medication being taken, level of diabetes control

being achieved, time since first diagnosis, and presence of complications.

8. Cigarette smoking. If a smoker or ex-smoker, ask about number of years spent smoking and

average number of cigarettes smoked per day. Does the patient also smoke roll-ups and cannabis? Does he use illicit drugs such as cocaine?

9. Alcohol. Ask about the number of units of alcohol consumed in a day and typical week. Note

that depending on the amount and type that is drunk, alcohol can be either protective or a

risk factor.

10. Diet. In particular, ask about fried food and takeaways.

11. Lack of exercise. Ask about amount of exercise taken in a day or week. Does the patient walk

to work or walk to the shops?

12. Stress. Ask about occupational history and home life.


Cardiovascular and respiratory medicine

Station 11 Cardiovascular risk assessment 25

Table 2. Desirable lipid levels

Total cholesterol < 5.0 mmol/l

LDL ‘bad’ cholesterol (fasting)  3.0 mmol/l

HDL ‘good’ cholesterol  1.2 mmol/l

Total cholesterol/HDL cholesterol < 4.5

Tryglycerides (fasting) < 1.5 mmol/l

NB. Patients at high risk of cardiovascular disease should aim

for even better than these figures.

After the assessment

If you have time, assess the extent of any cardiovascular disease.

Ask the patient if there is anything he would like to add that you may have forgotten to ask

about.

Give him feedback on his cardiovascular risk (e.g. low, medium, high), and, if appropriate,

indicate a further course of action (e.g. further investigations or further appointment to discuss

reducing modifiable risk factors).

Address any remaining concerns.

State to the examiner that appropriate investigations include:

– BMI (should be between 18.5kg/m2 and 24.9kg/m2

)

– waist circumference (should be less than 102cm for men and 89cm for women)

– blood pressure (should be under 140/90mmHg)

– fasting blood glucose levels (should be under 6.0mmol/L)

– fasting lipid levels (see Table 2)

Suggest calculating the patient’s 10-year cardiovascular risk score using the Framingham risk

equation, which takes into account a number of risk factors including gender, age, total cholesterol, HDL cholesterol, smoking status, and blood pressure.

Indicate that the management of cardiovascular risk factors includes lifestyle modification and,

if appropriate, medical intervention (see Table 3).

Table 3. Management of cardiovascular disease

Lifestyle modification Medical intervention

Advise patient to:

Stop smoking.

Reduce alcohol intake (to 3–4 units/day

in men and 2–3 in women, and avoid

binges).

Lose weight.

Adopt a healthy diet: reduce saturated

fatty acids, trans-fatty acids and

cholesterol; increase fibre and omega-3

fatty acids, e.g. from fish.

Take 30–60 minutes of exercise per day.

Consider statin for secondary prevention

or for primary prevention if 10-year risk is

>20%.

Consider anti-platelet drugs e.g. aspirin.

Consider anti-hypertensive agents.

If necessary, seek to optimise blood sugar

control.


Clinical Skills for OSCEs

26 Station 12

Blood pressure measurement

Before starting

Introduce yourself to the patient.

Confirm his name and date of birth.

Explain the procedure and obtain his consent.

Tell him that he might feel some discomfort as the cuff is inflated, and that the blood pressure

measurement may have to be repeated.

Avoid white coat hypertension by putting the patient at ease. Briefly discuss a nonthreatening subject, such as the patient’s journey to the clinic, or the weather.

The procedure

Select an appropriately sized cuff and attach it to the BP machine. This is usually a standard cuff

in all but children and the obese.

Position the BP machine so that it is roughly at the level of the patient’s heart.

Position the measurement column/dial so that it is at eye level (avoids parallax error).

Position the patient’s right arm so that it is horizontal at the level of the mid-sternum and free

from obstructive clothing.

Locate the brachial artery at about 2 cm above the antecubital fossa.

Apply the cuff to the arm, ensuring that the arterial point/arrow is over the brachial artery.

Inflate the cuff to 20–30 mmHg higher than the estimated systolic blood pressure. You can estimate the systolic blood pressure by palpating the brachial or radial artery pulse and inflating

the cuff until you can no longer feel it.

Place the stethoscope over the brachial artery pulse, ensuring that it does not touch the cuff.

Reduce the pressure in the cuff at a rate of 2–3 mmHg per second.

– the first consistent Korotkov sounds indicate the systolic blood pressure

– the muffling and disappearance of the Korotkov sounds indicate the diastolic blood pressure

Record the blood pressure as the systolic reading over the diastolic reading. Do not attempt

to ‘round off’ your readings; to an examiner’s ear, 144/88 usually rings more true than 140/90.

If the blood pressure is higher than 140/90, indicate that you need to take a second reading

after giving the patient a one minute rest.

In some situations, it may be appropriate to record the blood pressure in both arms (to investigate coarctation or dissection of the aorta), and also with the patient lying and standing (to

investigate for postural hypotension: a drop in BP on standing of ≥20mmHg).

After the procedure

Ensure that the patient is comfortable.

Tell the patient his blood pressure and explain its significance. Hypertension can only be confirmed by several blood pressure measurements taken over an extended period of time.

Thank the patient.

Document the blood pressure recording in the patient’s notes.

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