Information
You are the Senior House Officer in the cardiology clinic.
A patient has been referred on an urgent basis by his general practitioner for
investigation of chest pain.
Letter
Dear
Doctor,
Kindly see
Mr A (46 years) who complains of retrosternal chest pain for the last one month
Yours
sincerely
Dr.B
History
Use the method described in ACES for PACES chapter 4. The
mnemonic I passed by employing aces
will
help you remember to take a complete history without any omissions
Identification
Introduce yourself and clarify the identity of the patient
Analysis of Symptoms
Use the method described in ACES
for PACES chapter 4 . Use the mnemonic "Please Carefully Question These
Methods For Reliability and Resilience" to help you
analyse symptoms.
The patient describes a retrosternal chest pain that
radiates into his neck and to the shoulders
The pain is tightening in nature
It can be quite severe at times
It is often accompanied by sweating
The pain is brought on by exertion; he can walk about 100
metres before he develops the pain. He finds it difficult to climb stairs on
account of this.
Rest relieves the pain
The pain comes on rapidly when he reaches the limit of
exercise; it lasts several minutes and subsides fairly quickly when he rests.
This pattern of chest pain has been present for the last 3
months and he feels the frequency of episodes is increasing.
Analysis of Systems
See ACES for PACES appendix pages 583 to
586
CVS
No palpitations
No dyspnoea
No swelling of the ankles, abdomen or genitalia
No claudication
No cold extremities
No fatigue
No syncope
RS
No cough or wheeze
GIT
No heartburn, acid reflux, dyspepsia
KUS
No problems with micturition
CNS
No problems with speech, vision, movement
No sensory disturbance
LMS
No joint or bone pains or swelling
HS
No bleeding tendency
Past Illnesses
Nothing significant
Drug History
Not on any drugs
Drug Intolerance
None known
Allergies
None
Personal History
Eats a diet with a lot of red meat, low in fruit and
vegetables
Eats a lot of “fast food”
Does not do any exercise
Takes 24 units of alcohol per week
Smokes 20 cigarettes per day
Family History
His father died of a myocardial infarction at the age of 52
His mother died of breast cancer
He has a younger brother who is well
Social History
He is a social worker. He says the job involves a lot of
stress
He is married and has 2 young children aged six and eight
His wife works as a primary school teacher
They live in a 3 bedroomed house, which they own.
Beliefs
He thinks that he has heart disease, the type that his
father had
He is aware that this condition can have serious and fatal
consequences
Expectations
He expects to undergo a lot of tests
He also expects to take a lot of treatment and thinks he
may have to undergo a “bypass operation”
Anxieties
He is anxious that the cause of the illness is the fact
that he smokes and the fact that this condition runs in the family
He is afraid that this condition will affect his work and
that this may make it difficult for him to look after his family
He is also afraid that he may die of this condition
Analysis
Chest pain may be due to a number of causes
(ACES for PACES page 174)
With this distinct history, angina pectoris is the most
likely diagnosis. Other conditions such as gastro oesophageal reflux have been
effectively eliminated by the absence of related features when analysing systems
Diagnosis
Ischaemic heart disease (Angina pectoris)
Other Features
Belief that he has heart disease
Expectation of undergoing various tests and treatment
Anxieties regarding causes, effects and survival
Planning Investigation
(See chapter 18 ACES for PACES)
The main investigations in this patient would focus on:
Blood
Biochemistry to estimate cholesterol levels
Electrophysiology
Resting and exercise ECG
Imaging
Coronary angiography
Planning Management
(See chapter 18 ACES for PACES)
The mainstay of management in this patient would be
Medical
Cholesterol reduction
Blood pressure control if elevated
Aspirin
Clopidrogel
Surgical
Angioplasty, stent or bypass grafting
Lifestyle adjustments
Smoking cessation
Healthy diet
Regular exercise
Communication
(See chapter 18 Aces for PACES)
Explain to the patient your own:
Beliefs
He has ischaemic heart disease
Expectations
The tests that he will have to undergo
Treatment that he will have to undergo following
investigations
Also explain your views on:
Causes
Smoking
Unhealthy diet
Lack of exercise
Family history
Effects
Effects if untreated (angina, infarction, heart failure,
death)
Improvement with treatment
Survival
Chance of death would be reduced with treatment
