Chest Pain History-Case 2
Chest Pain History-Case 2
Please assess the student as they take the following history
Student's Email

CASE - The evaluating student should read the following case and role-play for their peer

 

Dear Student: The following exercise is meant to be done as a role-play.  One student should read the case and role-play the patient.  The other student should act as the physician, and should not read the case or the checklist in advance. A third student, or the "patient", should complete the checklist during the interview to track their peer's progress.

 

Case:  Ms. CP

 

You are Mr. CP, a 43 year-old single man who works as a contractor in home construction projects.  You are seeing the doctor because you have been experiencing episodes of chest pain that have been increasing in frequency.

 

About two weeks ago, you felt a pain in your chest as you were working fitting electronic wiring in a home.  The pain came on quite suddenly.  You were unable to locate where the pain was, exactly, though it was surely in the chest and felt as if it was spreading into your jaw as well.  The pain was a 5/10 at its worst.  You tried to sit down and rest and after about 1 minute, the pain went away and you were able to continue working.  Since that first episode, you have had 2-5 similar episodes per week during times of physical exertion.

 

Occasionally, you become short of breath during these episodes.  As with the chest pain, you can minimize the shortness of breath through rest.  The shortness of breath does not come with any wheezing or coughing.  You only experiences the shortness of breath during exertion; you never have it at night or when lying down.

  

You have two children, aged 11 and 13, from a previous relationship. You see your children frequently and get along with them well.  You do not exercise very often, though you are active through his job.  You smoke one pack of cigarettes per day, and have been for 25 years.  You consume about 2 beers per day.  You use no recreational drugs, nor does you have any allergies.  You are taking medications for hypertension and high cholesterol, but you can’t remember the names.  You have no other diagnosed medical illnesses.  You try to be compliant with your medications but forget a couple of times per week.  You see your doctor regularly for monitoring of your illnesses.

  

You have no family history of heart attacks, but your two older brothers (age 50, 52) are also being treated for high blood pressure.  You are concerned about the pain as if it gets any worse it may start to interfere with your ability to do your job.  Additionally, you are worried that the pain may be associated with your high blood pressure and high cholesterol.  You have had acid reflux in the past but this pain feels different—you are worried it’s your heart.

 

  

Stable Angina: Stable angina refers to chest pain due to reversible ischemia of the heart muscle.  It is most commonly due to the fixed stenosis of a cardiac blood vessel caused by atheromatous plaques.  While stable angina is predictable in its provocation, onset, and course, angina that occurs randomly without warning and/or lasts more than 15 minutes is called “unstable” and requires more serious medical attention.  The most common presenting symptoms for stable angina are: retrosternal chest pain that radiates and chest tightness.(see: http://www.onlinecjc.ca/article/S0828-282X%2814%2900356-0/pdf)

INTRODUCTION - The student should perform the following:

Washes hands
       
Introduces self
       

IDENTIFYING DATA- The student should inquire about the following:

Name of patient
       
Age of patient
       

CHIEF CONCERN - The student should inquire about the following:

Nature of concern

The most common sources of chest pain are: MSK-related (36%), GERD (13%), stable angina (11%), myocardial infarction (1.5%)

       
Duration of concern
       

HISTORY OF PRESENT ILLNESS - The student should inquire about the following:

Chest Pain

Onset of chest pain
               
Alleviating factors of chest pain
               
Quality of chest pain

Chest pain due to myocardial ischemia may present differently in different people.  Culture, gender (women often present atypically!), age, and co-morbidities may change the way pain is described.

               
Severity of chest pain
               
Radiation of chest pain

Chest pain due to cardiac cause often radiates to the neck/throat/lower jaw/teeth/shoulders.

               
Location of chest pain

Chest pain of due to cardiac cause is often very difficult for patients to localize.

               
Timing of chest pain
               
Course and progression of chest pain
               

Dyspnea

Onset of dyspnea

It is common for cardiac chest pain to be accompanied by exertional dyspnea.  Often, dyspnea brought on by exertion precedes chest pain brought on by exertion.

               
Alleviating factors for dyspnea
               
Exacerbating factors of dyspnea
               
Quality of dyspnea
               
Severity of dyspnea
               
Timing of dyspnea
               

General Questions

Associated symptoms
               
Previous similar episodes (includes: investigations related to these episodes)
               
Impact on quality of life and work performance
               
Family history of heart disease
               

PERTINENT POSITIVES AND NEGATIVES - The student should inquire about the following:

Constitutional Symptoms

(Differential diagnosis includes: cancer, infection, other systemic diseases)

Weight change
       
Fever
       
Fatigue
       
Change in appetite
       

Respiratory Symptoms

(Differential diagnosis includes: pulmonary embolism, pneumonia, asthma, COPD)

Wheezing
       
Pleuritic chest pain

Pleuritic chest pain is caused by inflammation of the pleural layers lining the lungs.  It is often described as a sharp/stabbing pain that is made worse with heavy breathing or coughing. 

       
Cough (includes: productivity, quality/quantity of sputum, blood in sputum)
               
Dyspnea
       
Exposures (includes: work exposures, travel exposures, infectious contacts)
               

Cardiac Symptoms

(Differential diagnosis includes: myocardial infarction, congestive heart failure, other myocardial dysfunction)

Dyspnea at night (paroxysmal nocturnal dyspnea)

Paroxysmal Nocturnal Dyspnea (PND) can occur in those with poor left-heart function.  After lying down, fluid redistribution due to gravity demands more activity from the left and right sides of the heart. In those who cannot match left-heart function with right-heart function, pulmonary congestion occurs, leading to symptoms of PND.

       
Dyspnea when lying down (orthopnea)

Orthopnea can occur in those with poor left-heart function when, after lying down, fluid redistributes due to gravity and causes pulmonary congestion.  It should resolve shortly after assuming a more erect position.

       
Palpitations
       
Swelling in legs
       
History of syncope
       
Personal or family history of heart attack, diabetes, hyperlipidemia, hypertension

The cardinal risk factors for cardiac disease: smoking, hypertension, diabetes, hyperlipidemia, family history.

               
ECG or stress test
       

Gastrointestinal Symptoms

(Differential diagnosis includes: GERD, esophagitis)

Regurgitation (includes: Does it taste acidic/sour)
               
Appetite changes
       
Odynophagia (painful swallowing)
       
Dysphagia (difficulty swallowing)
       
Abdominal pain
               
Nausea/Vomiting
               
Excessive gas (belching or flatulence)
               
Changes in stool (includes: constipation, diarrhea, rectal bleeding, melena)
               
Association of pain with eating
       
History of heartburn
       

Musculoskeletal Symptoms

(Differential diagnosis includes: trauma, rheumatic disease)

Muscle pain
       
Joint pain (includes: erythema, stiffness, swelling, tenderness)
               
History of recent trauma
       

Psychiatric Symptoms

(Differential diagnosis includes: anxiety)

Nervousness/anxiety
       
Recent major changes in life/major stressors
       
Personal or family history of depression or other mental illness
               

MEDICATIONS AND ALLERGIES- The student should inquire about the following:

Medications (includes: prescription, over-the-counter, and herbal/alternative medicines)
               
Allergies to drugs or otherwise (includes: nature of reaction, timing of reaction, formal testing performed)
               

PAST MEDICAL HISTORY - The student should inquire about the following:

It is important to ask about diagnosed medical illnesses, surgeries, hospitalizations, and immunization history.  However, all relevant aspects of Past Medical History have been covered in the pertinent positives/negatives section (i.e. personal history of hypertension, hyperlipidemia, diabetes).

SOCIAL HISTORY AND HABITS- The student should inquire about the following:

Smoking (includes: pack years; if they quit, when)
               
Alcohol (includes: quantify)
               
Drugs (includes: types, frequency of use, quantity, methods)
               
Living arrangement
               
Relationships & Children
               
Hobbies & Interests
               
Occupation
               

REVIEW OF SYSTEMS - The student should inquire about the following

Though it is important to perform a thorough review of systems when seeing patients, this is not relevant for this case.