patient cases

Question 1

what 4 diagnosis jump to mind for chest pain

Answer 1

acute coronary syndrome
stable angina
gastroesophageal reflux
pectoral muscle injury

Question 2

analytical diagnosis

Answer 2

when you have little idea what the problem might be 
slow 
effortful
for uncommon conditions 
use google and NICE

Question 3

intuitive diagnosis

Answer 3

illness script - see it more often
common patterns link to diagnosis
fast
more prone to bias/error

Question 4

symptoms of aortic stenosis

Answer 4

breathlessness, chest pain, lethargy, balance issues, decreased activity

Question 5

how do you form a diagnosis

Answer 5

data is applied to hypothesis

do physical examination

Question 6

process of diagnosis

Answer 6

look at presenting symptoms
look at history - beware of distractions
look at examinations

Question 7

common cause of chest pain in primary care

Answer 7

musculoskeletal

Question 8

common cause of chest pain in A and E

Answer 8

cardiac

normally more serious than in primary care

Question 9

chest pain aggravated by breathing

Answer 9

musculoskeletal

Question 10

chest pain worsened by exercise

Answer 10

cardiac

Question 11

chest pain from eating

Answer 11

cardiac (could be GI too)

Question 12

sharp stabbing pain

Answer 12

musculoskeletal

Question 13

pain from fall

Answer 13

maybe musculoskeletal

Question 14

chest pain and diabetes

Answer 14

cardiac/GI

Question 15

dull chest pain

Answer 15

cardiac

Question 16

smoker, and stress in job causing chest pain

Answer 16

cardiac

Question 17

chest pain causing nausea and sweat

Answer 17

cardiac

common for MI

Question 18

pathway of diagnosis for musculoskeletal problem

Answer 18

percussion of lungs to see if PE
see if there has been a spontaneous fright, anxiety, palatations, dyspnoea or fainting (MSK no)
see if pain reproducible by palpation (for MSK it is)
chest wall pain
(if not reproducible by palpation = heart failure/GI pathology)

Question 19

pathway of diagnosis for angina

Answer 19

have typical/atypical anginal pattern, pain radiation, diaphoresis or cardiac risk factors
ECG normal - no ST elevation
troponin levels - slightly abnormal - should still be outpatient because don’t want to bring people in every time that they have an angina attack to decide look at ECG while they are exercising
with moderate risk and abnormal ECG - stress test with perfusion scan
high risk - perform angiography

Question 20

pathway of diagnosis for acute coronary syndrome

Answer 20

ECG normal
troponin marker for CV damage - high
MI/heart attack
evaluate as an inpatient

Question 21

continuum of cardiac problems

Answer 21

few atherosclerotic symptoms 
might have anginal attack 
then low level MI 
cause heart abnormalities eg arrhythmia
mean each MI is more severe

Question 22

main lifestyle recommendations for cardiac

Answer 22

control diet

Question 23

problem with diet advice

Answer 23

delivery is not proof of receipt

concept that it is less important that a drug

Question 24

good fats

Answer 24

monosaturated fatty acids (plant), polyunsaturated fatty acids (fish)
liquid at room temp
HDL
cardio protection
Mediterranean diet
epidemiology - Mediterranean countries disease trend not raise same as uk

Question 25

bad fats

Answer 25

LDL
unhealthy diet
change little things and incorporate into daily life

Question 26

salt

Answer 26

intake should be reduced
associated with increased bp - increase water retention - increased pressure - increased hypertension
SBP - increases the most - for target to be reached - need to change ingrained behaviour
hypertension CVD that can cause other CVD eg kidney, eye, liver damage

Question 27

fruit and veg

Answer 27

need more fruit and veg based diet
better than processed food
increase of 1 portion a day reduce risk CHD 4% and stroke 6%
extra 1.4 portion a day reduce SBP by 4mmHg

Question 28

alcohol

Answer 28

small amount - cardioprotective effects
as consumption increase - risk increase incrementally
J shaped curve between mortality and ethanol

Question 29

reporting alcohol

Answer 29

self report unreliable

they don’t want to feel judged/or they don’t realise how much they drink

Question 30

recommendation for alcohol

Answer 30

reduce

Question 31

recommendation for diet

Answer 31

fat - <10% saturated energy 
salt  <6g/d
fruit and veg >5 portions day 
alcohol <21units/w male 
<14units/w (female)