Patient with Non-Cardiac Chest Pain

Kofi Mensah is a 70-year-old gentleman you visit at his home with your practice assessor. He is married to Agnes and they have a 40-year-old daughter and 4 grandchildren.

He has recently been discharged from hospital after falling down the stairs at home. He is complaining of pain in his chest. This is not cardiac related; his discharge letter confirms that he has a fractured rib as a result of his fall.  Kofi has been seen this morning by his GP and has been prescribed analgesia. He is reluctant to take these regularly for fear that he will become addicted. He is speaking very slowly due to the pain and is finding it difficult to share information with you.

He worked as a pub landlord but retired a few years ago due to poor health. He used to have a very active social life but has not been able to go out for some time because of limited mobility. He has become withdrawn but enjoys seeing his grandchildren and close family members.

 

Observations

  • Airway: Able to talk and responding to questions.
  • Breathing: RR – 26 breaths per minute. SpO2 – 98% on air.  Breathing is shallow as he finds it painful to take full breaths.
  • Cardiovascular: HR 80 bpm, BP 130/90 mmhg, skin feels cold to touch.
  • Disability: ACVPU Alert
  • Exposure: Temperature 36.4°C.

 

Signs and Symptoms

  • Pain in his chest (Pain score 8/10)
  • Loss of appetite
  • Low mood
  • Constipation
  • Limited mobility

 

Past Medical History

  • Osteoarthritis
  • Depression
  • Hypertension
  • CVA with residual left sided weakness

 

Current Medication

  • Co-codamol 50/500mg, 2 tablets TDS
  • Amlodipine 10mg once a day
  • Atorvastatin 40mg once a day
  • Fluoxetine 40mg once a day
  • Multivitamins

 

Family History

  • He has a brother addicted to pain killers and this is a concern for him.

 

Social History

  • Smokes 5 cigarettes a day
  • Occasionally drinks 2-3 units of beer
  • Relies on Agnes to help with most of his activities of daily living but this is taking its toll on their marriage.
  • Agnes is very concerned and struggling to cope.

 

Discuss one assessment strategy for this symptom/sign and explain the underlying pathophysiology.

 

 

NOTE

PLEASE USE ABCDE APPROACH TO ASSESS THE PATIENT

 

 

 

 

 

 

 

 

 

 

 

 

 

Case Study 2: The Patient with Shortness of Breath

Hayley Smith is a 32-year-old female patient, who works in retail as an Assistant Manager in a high street shop. She attended A&E this afternoon complaining of shortness of breath and wheezing which started early this morning but has progressively worsened. She has used her blue inhaler, but this did not relieve her symptoms. She ran out of her ‘preventer’ inhaler 5 days ago. Hayley says she has had attacks like this before, so knew to come into hospital as when she feels like this, she knows she needs help. She has a new-born baby at home.

A&E is very busy, and Haley is anxious to get home to her son.

 

Observations

  • Airway: Patent, able to talk and respond to questions.
  • Breathing: RR – 34 breaths per minute, SpO2 – 92% ~ 40% oxygen delivered via face mask. Using accessory muscles, hunched over, audible wheeze without a stethoscope, cannot complete full sentences.
  • Cardiovascular: HR 134 bpm, BP 98/53 mmhg.  Doesn’t remember last time she passed urine but doesn’t think there are any problems. Flushed and sweating, warm peripheries.
  • Disability: AVCPU Alert, Capillary Blood Glucose – 5.2 mmol/l.
  • Exposure: Temperature 36.9°C.

Social History

  • Single mother
  • Breast feeding
  • Ex-smoker – stopped during pregnancy
  • No alcohol since knowing about pregnancy
  • No recent travel

 

Signs and Symptoms

  • Hayley describes palpitations, feeling hot and sweaty, tight chest, but no pain.

 

Past Medical History

  • Gave birth to son Max, 4 weeks ago, after 23-hour labour via c-section, due to baby distress.
  • Asthma – has been admitted to ICU 3 times in the past year before her pregnancy.
  • Postnatal depression
  • Anxiety

 

 

Current Medication

  • Paracetamol 500 mg, 2 tablets QDS
  • Beclomethasone inhaler, BD
  • Salbutamol Inhaler, PRN

 

Family History

Mother has type 2 diabetes.

 

Social History

  • Single mother
  • Breast feeding
  • Ex-smoker – stopped during pregnancy
  • No alcohol since knowing about pregnancy
  • No recent travel

 

Discuss one assessment strategy for this symptom/sign and explain the underlying pathophysiology

 

NOTE

PLEASE USE ABCDE APPROACH TO ASSESS THE PATIENT

 

 

 

 

 

 

 

 

 

 

 

 

Case Study 3: The Patient with Tachycardia

Arjun Bakta is a 58-year-old gentleman of Hindu heritage. He came to England from Punjab with his parents when he was a child.  He is married to Nisha and they have 4 adult children.  Two of their children live at home, along with Arjun’s mother who is 82. They live in a 4-bedroom terraced house.

Arjun has a PhD and works as a laboratory technician for a pharmaceutical company. He finds his work incredibly stressful due to staff shortages and is expected to work long hours. This has resulted in him having episodes of anxiety and depression which he does not like to discuss. Gradually, he is beginning to lose interest in his job and phones in sick regularly.

He has come into A&E via his GP with tachycardia, palpitations and shortness of breath.

 

Observations

  • Airway: Patent, no issues. Able to talk in short sentences.
  • Breathing: RR – 22 breaths per minute, SpO2 – 95% on air. No wheezing or added sounds.
  • Cardiovascular: HR 120 bpm, BP 115/84 mmhg, (usual BP is 148/88). ECG shows fast AF.  Peripherally warm. Passing urine via commode.
  • Disability: AVCPU Alert. GCS 15/15 but feeling lightheaded and dizzy. Exposure: Temperature 36.2°C.

 

Signs and Symptoms

  • Palpitations
  • No pain

 

Past Medical History

  • Hypertension
  • Obese – BMI 37 (180cm/120Kg)

 

Current Medication

  • Ramipril 2.5mg, BD

 

Family History

  • Father passed away from stroke 10 years ago.
  • Mother has hypertension and type 2 diabetes.

Social History

  • Ex-smoker, 30 pack years. Gave up 8 years ago.
  • Enjoys rich high fat foods.
  • Inactive lifestyle
  • No drug or alcohol use.

 

 

Discuss one assessment strategy for this symptom/sign and explain the underlying pathophysiology.

 

 

NOTE

PLEASE USE ABCDE APPROACH TO ASSESS THE PATIENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Case Study 4: The Patient with Altered Conscious State

John Kelly is 82 years old and was admitted to the ward this morning via A&E having fallen at home. John is a widower and has been living on his own for the last 6 years since his wife died. He has 4 grown up children (3 sons and a daughter), 7 grandchildren and 12 great grandchildren.

John’s eldest son and daughter-in-law live nearest to John, so came to the hospital with him and are now on the ward. Physically John appears to be well and, although bruised, x-rays show that he has no fractures. However, John seems to be confused and when you ask his son about this, he insists that his father is ‘just being awkward as usual’. However, John’s daughter-in-law appears concerned and reports that she thinks John has become increasingly confused over the last 2 weeks.

 

Observations

  • Airway: Patent, no issues. Able to talk in full sentences.
  • Breathing: RR – 16 breaths per minute, SpO2 – 93% on air. No wheezing or added sounds.
  • Cardiovascular: HR 80 bpm, BP 160/80 mmhg (normal range for him).  Has passed small amounts of urine frequently since admission. Peripherally warm.
  • Disability: AVCPU Confusion – GCS 13/15 [E(4) V(3) M(6)]. John seems very quiet and easily distracted by what is going on around him. He also keeps asking for his wife and trying to leave to find her.
  • Exposure: Temperature 36.8°C. No rashes or breaks to the skin observed.

 

 

Signs and Symptoms

  • Reports ‘being sore’ but is vague about where he has pain.

 

 

Past Medical History

  • Knee replacement 10 years ago.
  • Family reports he was depressed for about a year after his wife died.
  • Anxiety Disorder

 

Current Medication

  • Furosemide 20mg

 

Family History

  • Mother died of cancer aged 38 when he was 7.
  • Father died in his sleep aged 78.
  • John’s younger sister has been recently diagnosed with Alzheimer’s disease.

 

Social History

 

  • Non-smoker
  • Goes to the pub on a Friday lunchtime and has 2 pints of beer. Likes a shot of whisky every night before bed.
  • Doesn’t like cooking so tends to rely on microwave meals but does have a roast dinner at his eldest son’s house every Sunday.
  • Usually active – still walks to the local shop for his paper every day.

 

 

Discuss one assessment strategy for this symptom/sign and explain the underlying pathophysiology

 

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