OSCE
CHES) PAIN = (AML)
Mr Jones, a 47 vear old man, presents to the emergency department with epigastric pain. Please
take a history after which I shall ask you for vour differential diagnosis. I will then ask you some
questions about managing this patient.
* Introduce self
+ Pain questions
* where is the pain (upper epigastrium)
* quality of pain (like a tight band. like someone sitting on me)
+ duvation (hegan hrs ago. lasted 1 $ hee)
* severity (really bad, worst I've had)
* pattern of pain (sudden onset, persistent)
* radiation (to shoulder tip and down arm)
* associated events (came on this moming while I was at breakfast)
* relievers (GTN helped a bit) 13
* aggrevaiors (nothing)
+ Associated symptoms
* sweating (99)
** nausea, vomiting (ves)
* dizziness (yes)
* apprehension (thought ] was going to die)
* restlessness (couldn't sit still)
* shortness of hreath (nay
*+ Review of systems
*CVS
* Regpinaiory (vould be PE)
* GIT perforated peptic ulcer etc)
+ Risk factors LS
* family history (positive)
30 pack-year history)
* hyperlipidaemia (never had it done)
* diabetes (no)
* hypertension (not sure)
3
13
5
Ss
3
5
wun
s+ What is the most likely diagnosis?
* aM 1
unstable angina, perforated peptic ulver. PE 3
+++ What investigations would you like to do’.
*ECG 1
~ ST elevation, T inversion
= reciprocal ST depression
Qwaves~ Troponins (cardiac specific troponin T and wupunin 1)
+ AST }
-LDH
*CXR
* FBE (polymorphonuclear leucocytosis in first few days)
+++ Troponins are raised. ECG changes: do these results bear out your original diagnosis?
s++ How would you manage this patient?
* Aspirin
* Ihrombolyuc therapy
+ streptokinase, reteplase (rP.A), tissue plasminogen activator
* Percutaneous transluminal coronary angioplasty (PTC.\)
+ if contra-indications to thrombolytic therapy. age 70, cardiogenic shock.
* Admit to CCU.
sontinuous ECG monitoring
* Pain control
~ morphine. nitrogl»vctine (1efiactury pain), 6 Blockers
* Oxygen
* Mild Sedation (diazepam)
* Beta blockers
* Heparin
* ACE intibiiors
* measure and correct (if necessary) serum magnesium to prevent arrhythmias.
TOTAL 20