Chest pain

Question 1

Differentials of chest pain

Answer 1

1) Cardiac (MI, pericarditis, aortic stenosis)
2) GI (gastritis/ulcer secondary to naproxen, GI bleed, GORD, oesophageal malignancy, pancreatitis, biliary colic)
3) Respiratory (PE, pleurisy, pneumonia, lung cancer)
4) MSK (muscular, shingles, costochondritis, aortic stenosis, se statins)
5) Vascular (dissecting aneurysm)

Question 2

Differentials of swollen ankle

Answer 2

1) Cellulitis
2) Oedema
3) Osteoarthritis/lymphoedema
4) Fracture
5) Gout
6) Inflammatory arthritis
7) Septic arthritis
8) DVT

Question 3

Differentiating hx of cellulititis

Answer 3

Red, hot ankle, fever, ankle joint movable

Question 4

Differentiating hx of oedema

Answer 4

Pitting

Question 5

Differentiating hx of osteoarthritis/lymphoedema

Answer 5

No pitting, no trauma

Question 6

Differentiating hx of fracture

Answer 6

Evidence of trauma

Question 7

Differentiating hx of gout

Answer 7

Red, hot ankle, no fever, no swollen calf, no pain in other joints

Question 8

Differentiating hx of inflammatory arthritis

Answer 8

Red, hot ankle, no fever, no swollen calf, pain in multiple joints

Question 9

Differentiating hx of septic arthritis

Answer 9

Red, hot ankle, fever, ankle joint unmovable

Question 10

Differentiating hx of DVT

Answer 10

Red, hot ankle, no fever, swollen calf

Question 11

What should be taken into account when prescribing NSAIDs?

Answer 11

When prescribing an NSAID, individual risk factors for adverse effects should be taken into account and include any contraindications, drug interactions, medical history, and any monitoring requirements.

Question 12

Can people with heart failure take NSAIDs.

Answer 12

Yes depending on the severity of the heart failure.
• Severe heart failure — NSAIDs should be avoided.
• Mild, moderate, or severe heart failure — COX-2 inhibitors, diclofenac, and high-dose ibuprofen (2400 mg or more daily) should be avoided.
• Mild to moderate heart failure — a standard NSAID should be prescribed (but not diclofenac or high-dose ibuprofen), and the person should be monitored closely.
• Ibuprofen up to 1200 mg daily, or naproxen up to 1000 mg daily, should be first-line options.

Question 13

Can people with CVD take NSAIDs?

Answer 13

Yes.
For people with ischaemic heart disease, cerebrovascular disease, or peripheral arterial disease, ibuprofen up to 1200 mg per day or naproxen up to 1000 mg daily, should be first-line options.

Question 14

Which NSAIDs are CI in people with CVD?

Answer 14

COX-2 inhibitors, diclofenac, and high-dose ibuprofen are contraindicated.

Question 15

Can people with renal impairment take NSAIDs?

Answer 15

No but if used, they should be monitored closely.
For people with severe renal impairment (estimated glomerular filtration rate [eGFR] less than 30 mL/minute/1.73 m2), ideally NSAIDs should be avoided.
If an NSAID is used, the person should be monitored closely.

Question 16

What should a doctor do to prevent GI adverse effects associated with NSAIDs?

Answer 16

• An alternative analgesic should be considered.
• Prescribing more than one NSAID at a time should be avoided.
• Concomitant use of an NSAID with low-dose aspirin should be avoided
• Short-acting NSAIDs (such as ibuprofen) should be used in preference to long-acting formulations (such as naproxen).

Question 17

WHat can be done for people at risk of GI adverse events with NSAIDs?

Answer 17

• High risk of GI adverse events — a COX-2 inhibitor should be prescribed with a proton pump inhibitor (PPI).
• Moderate risk of GI adverse events — a COX-2 inhibitor should be prescribed alone, or an NSAID plus a PPI.
• Low risk of GI events — a non-selective NSAID should be prescribed.

Question 18

What is the problem with taking SSRIs and NSAIDs?

Answer 18

Selective serotonin uptake inhibitor (SSRI) itself can increase the risk of bleeding, particularly within the GI tract when combined with an NSAID.

Question 19

What advice should be given to a patient on NSAIDs and SSRIs?

Answer 19

The risk of bleeding should still be communicated to the patient; he should be advised not to suddenly stop his antidepressant, but to report any indigestion or stomach upset.
PPI should be prescribed as well

Question 20

What is a significant event?

Answer 20

1) A significant event (also known as an untoward or critical incident) is any unintended or unexpected event, which could or did lead to harm of one or more patients.
2) This includes incidents which did not cause harm but could have done, or where the event should have been prevented.

Question 21

What is a cognitive bias?

Answer 21

1) Cognitive bias is an error in thinking, reasoning or evaluating, which in medicine can lead to the wrong diagnosis for a patient.

Question 22

What is anchoring bias?

Answer 22

Anchoring bias is a form of bias where an individual depends too heavily on an initial piece of information. For example, when patients are repetitively clerked in hospital, we often refer to the initial diagnosis without questioning and checking.

Question 23

What is availability bias?

Answer 23

The tendency to let an example that comes to mind easily (because you have recently seen or been taught about it, or you had a particularly vivid experience of the case) affect your decision making or reasoning.

Question 24

What are the three common causes of epigastric pain?

Answer 24

MI, pancreatitis and gastric erosions.

Question 25

Clinical features of MI

Answer 25

• S- central chest
• O- sudden onset
• C- crushing, tight, heavy
• R- radiate to neck/jaw/arms/back
• A- pain on effort (physical, emotional, cold wing, meals)
• T- continuous pain > 15 minutes
• E- associated nausea, vomiting, SOB, sweatiness
• S- sever, not relieved by rest or GTN

Question 26

Clinical features of pancreatitis

Answer 26

• S- Epigastric pain/ LUQ
• O- sudden onset
• C- severe, dull pain
• R- may radiate to back and L shoulder
• A- Associated nausea or vomiting, diarrhoea, fever
• T- constant
• E- eating or drinking may make worse, curling into a ball may help relieve pain
• S- severe

Question 27

Clinical features of gastric erosions

Answer 27

• S- Epigastric pain though can be retrosternal
• O- sudden or gradual
• C- burning ‘heartburn/dyspepsia’
• R- radiate to neck, back, umbilicus
• A- nausea, reduced appetite
• T- lasts few minutes to hours
• E- triggers: few hours after meals, NSAIDs, some relief initially with antacids/PPI
• S- variable

Question 28

Why is a DRE performed if a GI bleed is suspected?

Answer 28

A DRE could be indicated in this case to exclude melaena or fresh blood – which would be a sign of a GI bleed.

Question 29

What should be offered before performing a DRE?

Answer 29

It is important before any examination, but particularly with an intimate examination, that a chaperone is offered.