Virtual Patient Daniel Underhill
You are an FY1 doctor in the medical admissions unit where you are clerking patients who have been sent up by their GP, it is 10am.
The next patient to be seen is Mr Daniel Underhill, he is a 73 year old man who lives at home with his wife:
What Would You Like to Do?
Dear Medical Team,
Thanks for seeing Mr Underhill. He is a pleasant 73yr old man who presented this morning with ischaemia saudi chest pain. He has a past medical history of MI 10 years ago & also has light blood pressure.
I would be greatful for your review & management of this possible MI.
Yours Sincerely, Doctor Glen.
Oh I had a terrible pain in my chest. It woke me up from sleep this morning. It didn’t get any better with that spray, so my wife, Betty, made me go and see my GP and he sent me in here.
The pain was right in the centre of my chest and it felt really heavy but didn’t spread or move anywhere else. I did feel a bit sick and sweaty with it. It lasted about 1 hour in total but now seems to have gone.
I had a heart attack 10 years ago and I have high blood pressure but otherwise I ‘m in fairly good nick, I walk down for the papers every day. I have to admit though smoking is my vice, I smoke about 20 per day but I don’t touch a drop of alcohol, nasty stuff.”
You then ask Mr Underhill about medications and allergies:
“Currently I take Aspirin 75 mg in the morning, Simvastatin 40mg at night and Ramipril 5mg twice a day, and I have a wee spray for under my tongue when I get the angina. I’m not allergic to anything that I know about.
You then gain consent and perform a full examination, you find only nicotine staining on Mr Underhill’s fingers and that he is slightly overweight.
What Do You Think is the Most Likely Diagnosis?
Mr Underhill describes cardiac sounding chest pain; however there are some features that suggest it may be more serious than his normal angina.
Good. Mr Underhill describes chest pain that would be in keeping with an Acute Myocardial Infarction.
This is a possible differential diagnosis for chest pain, but Mr Underhills pain sounds cardiac in nature. Muscular pain is not associated with feeling sweaty or sick and is unlikely to come on suddenly waking him from sleep.
This is a possible differential diagnosis for chest pain but does not sound likely in Mr Underhills case. Gastritis is usually described as a burning sensation, it is often associated with certain foods, lying down or stooping. It is not associated with feeling sweaty or sick. Similar pain can often be elicited by palpating the epigastrium in patients with this condition.
In a patient with a pulmonary embolism you would expect them to describe pleuritic chest pain, Mr Underhills sounds more cardiac in nature.
What Investigations Would You Like to Request?
Good. Troponin is a protein that is released when there has been myocardial damage. However it can be elevated in a number of different conditions including pulmonary embolism and heart failure. It therefore must not be used in isolation but in the context of the patients history.
Results: The Troponin has come back at 0.9
Great. A chest xray can help rule out other important differential diagnosis such as aortic dissection where you would see a widened mediastinum.
Results: Chest xray is normal.
Excellent, this can be a diagnostic test patient having a heart attack.
Results:
Click to enlarge
What Do You Think the Most Likely Diagnosis is Now:
Great this is the most likely diagnosis given the history on elevated troponin
Mr Underhill has an elevated troponin and therefore it is more likely that he has had an NSTEMI, however this will need to be confirmed with a 12 hour troponin.
There is no ST elevation on the ECG.
What is Your Management Plan Now?
Good. This is the best environment for someone who has had an NSTEMI.
Good. Mr Underhill now needs 300mg of Aspirin.
Good. My Underhill now needs 300mg of Clopidogrel.
Good. Mr Underhill now needs Fondaparinux 2.5mg S/C.
Great, it is recommended that all patients who have acute coronary syndrome should receive continuous cardiac monitoring as they are at risk of arrhythmias.
Great this will allow confirmation of the diagnosis of NSTEMI.
Mr Underhill has now been admitted to CCU with cardiac monitoring and has had all his initial treatment and is awaiting his 12 hour troponin.