Gen Med 2

You are an intern at GCUH and you have been told by your registrar to see Janet, aged 65,
who has just been triaged by the nurse. She has presenting because of new onset chest
pain.

Task
Take relevant histories and perform relevant physical exam on Janet. Report back to your
registrar and include an assessment and your recommendations.
SP information

Janet, age 65, female

Presenting complaint
 Central chest pain

History of presenting complaint

 Came on 2 hours ago
 Left side of the chest
 Sharp quality
 7/10
 No radiation and hasn’t moved anywhere else
 Aggravated by deep breaths and position doesn’t change the severity of the pain
 Associated with dyspnoea and dyspnoea worse on exertion
 Cough and feeling warm
 Never had anything like this before

Past medical history

 History of breast cancer
 Bilateral mastectomy with full lymph clearance 3 weeks ago
 Was hospitalized for 3 days
 Good recovery thus far
 No cardiac, respiratory or thromboembolic conditions
 Allergic to penicillin
 On oral anastrozole at the moment

Social history
 Ex-smoker (20 pack years)
 Social drinker
 No recreational drugs
 Works as a retired high school teacher

Physical exam
 BP 130/80 HR 130 RR 34 T37.6 SaO2 94%RA
 Tachypnea and tachycardia
 Decreased breath sounds on auscultation
 Raised JVP
 L) leg erythematous evident on inspection
Investigations
 Baseline bloods
o FBC, Chem20, ESR, CRP
o ABG
 Confirm/exclude diagnosis
o PERC score can be used to exclude PE clinically without any tests in certain
patients
o D-dimer if low PE wells score
o CTPA (or v/q if contraindicated)
 Investigate severity
o ECG (tachycardia, RV strain i.e. t-wave inversion in right precordial and
inferior leads. RBBB, RAD, S1Q3T3)
o CXR (wedge infarcts, regional oligaemia, enlarged pulmonary artery, effusion)
o Echocardiogram
o Bilateral leg doppler
Management