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A 59 yr old woman presents to the surgery. Patient presents saying:“I’m really scared doctor, I’ve had chest pain for the last 2 hours and I’m feeling out of breath!”What questions further questions will you ask to expand the presenting complaint?With each question you ask think about possible answers and what they would imply:Question Possible response What this meansSWhere is the pain1.Centre of my chest2. in my shoulderOCRATESMore history:“I’ve never had any chest pain like this in the past doctor, nothing like this at all! It’s on the left side of my chest and it’s really really sharp. It came on suddenly whilst I was on the toilet and has remained pretty severe since, I’d say about 7/10. It doesn’t move anywhere else but it’s definitely made worse when I take a deep breath, it’s probably 9/10 when I do that. Since the pain started I’ve also been feeling short of breath, I’m not sure it came on at exactly the same time, but it was pretty close. ? Lying down, leaning forward and exertion don’t seem to make much of a difference to the pain, but I do get more short of breath when I exert myself.”“I feel a little short of breath when I’m at rest like this, but it gets a lot worse when I’m walking. I’m normally pretty fit, I manage to get to the shop and back, which is up a hill, without stopping or feeling short of breath. I haven’t had any illnesses in the last few weeks as far as I know and I don’t think I’ve been in contact with anyone else who is unwell. I haven’t noticed any wheezing but I did have some surgery about 3 weeks ago, a laparoscopic hysterectomy for all the fibroids that were causing me trouble. I haven’t been on any holidays in years, I wish I had!”What is your differential diagnosis?Are there any other questions that may be helpful in the history? Think risk factors, drug history etc.“I have some arthritis in one of my knees, but it doesn’t cause me too much trouble, then I’ve got the fibroids, but I guess they’re gone now. Other than that, I’m pretty well, I don’t even have any allergies!”. “I take some paracetamol and ibuprofen for my knee when it’s bad. No contraceptive pill for me, I’m well past that stage and thankfully haven’t needed any hormonal replacement therapy either.”“I live with my husband in a flat and neither of us smokes. We used to have a dog but she died last year sadly. My only hobby is selling handmade terrariums? on Etsy, does that count?”“I haven’t travelled anywhere in years and I’ve not got any other symptoms that I’m aware of.”My differential diagnosis includes........for each condition describe the typical history:Condition Typical historyPEPneumothoraxACSPneumoniaAortic dissectionYou now need to examine the patient, what approach will you use when examinining an acute medical problem and help you present your findings?O2 saturation on air? – 89%Respiratory rate? – 22Auscultate the lungs to assess air entry? –? a pleural rub is heard over the right lower lobeBP? – 130/82Pulse? – 132 –? regularCRT? – ? < 2 secondsAre there any other examinations/Ix you would like to do?You admit this patient to A&E. What is the immediate management for this patient?What is the long-term management?An?ABCDE? approach would be the most appropriate way to carry out the initial assessment to ensure the patient is stable.AirwayThe patient is able to speak to you in full sentences, therefore her airway is patent.? BreathingO2 saturation on air? – 89%Respiratory rate? – 22Give high flow oxygen via a? nonrebreather? mask? –? the patient is hypoxic (aim sats >94%)Auscultate the lungs to assess air entry? –? a pleural rub is heard over the right lower lobe? CirculationBP? – 130/82Pulse? – 132 –? regularCRT? – ? < 2 seconds? Gain IV accessPerform ABG:pH- 7.36PaO2 = 8.00kPa (↓)PaCO2 = 5.5 kPa? Bicarbonate – 23? ? ECG? –? shows sinus tachycardia? Disability? GCS –? 15Pupils equal and reactive to light.Normal power in all four limbs.? ExposureNo evidence of external bleeding.No rashes.Healing port site wounds from laparoscopic hysterectomy noted? (they appear healthy).Calves are soft and non-tender.After you place the patient on 15L of high flow oxygen, O2?saturations increase to 94% and her respiratory rate decreases to 19. Well done. ................
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