AKT questions

1. A 43 year old woman presents with an episode ofsevere pain in her upper abdomen of one hours duration and one vomit. She has had three previous episodes one of which woke her at night and lasted for two hours. She is now asymptomatic. She has tenderness on inspiration in her right upper quadrant.

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: H

Chest pain in primary care is sometimes straight forward but can be one of the most challenging tests of decision making in Primary Care. Generally speaking there is limited use made of the Troponins (specific and sensitive for myocardial damage) and the D Dimer (sensitive but too non specific). Too often the results of the latter are telephoned through to a hapless out of hours doctor who has no clinical details to guide him! Although I might occasionally do a Troponin T (for instance in an elderly person with co-morbidity, full safety netting and reliable social support) I would only do so after a full clinical assessment, ECG and in the knowledge that an MI was clinically unlikely. I would take personal responsibility for checking the result.Biliary pain (case 1) is occasionally confused with cardiac pain, as is the characteristic L sided pain of the stressed executive (case 2). Such a patient will often end up with an exercise test for his own reassurance but, since this is not totally specific or sensitive may be superseded by cardiac CT in the future.

2. A 48 year old sales manager with no medical history presents following a medical by a private insurer. The examining doctor was concerned about his left sided chest pain which came on at variable times, was sharp in quality and which the patient associated with stress. A full biochemical screen and ECG at the medical were normal

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: A

3. A 70 year old patient telephones to tell you that he has had severe retrosternal pain for 30 minutes and has vomited once. His wife has told him that he looks dreadful

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: B

Myocardial infarction is the likely cause of the problems encountered by Case 3. There is no mileage in delaying admission these days but it important that the patient (or representative) is spoken to directly. If there is an aspirin in the house he should be advised to take it.

4. A 25 year old woman presents with R sided chest pain which has occurred in conjunction with an URTI. Clinically she is normotensive with a pulse rate of 90 regular, some chest wall tenderness and reproduction of pain on thoracic spine rotation. She takes the contraceptive pill.

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: A

The young lady in case 4 is clinically unlikely to have a pulmonary embolus (but this should be considered) and a D Dimer of course could well be a distractor in the presence of a URTI. She is most likely to have pulled an intercostal muscle coughing.

5. A 40 year old police cadet was thumped in the ribs three days before during unarmed combat training. He has L sided chest pain worse on breathing and moving but has been able to work. Apart from rib tenderness clinical examination is unremarkable, he is normotensive and his oxygen saturations are 98% on air

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: A

The policeman in case 5 does not need further investigation (the most worrying consequence of his injuries is a tension pneumothorax which in this scenario is unlikely – A&E doctors may argue with this but it is unlikely to change management in primary care).

6. A 43 year old labourer presents with a short episode of severe thoracic spine pain earlier in the day which settled after 40 minutes or so. He had a previous episode the week before. On examination he looks well, BP 90/60, pulse 100 regularly and he has a soft early diastolic murmur.

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: B

Case 6 is seriously ill. Check the BP in both arms (it may be different), insert a venflon if you have one and stay with the patient until the ambulance arrives. He probably has an aortic dissection (has he got Marfan.s syndrome?) and your action could be life-saving.

7. A 58 year old French teacher has a persistent cough and a niggling R sided chest pain. She smoked 20 cigarettes a day until 3 years ago

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I.Refer to the Rapid access chest pain clinic

Answer: F

I would be concerned that case 7 had a carcinoma of the bronchus and would order a Chest X-Ray. If this was normal I would review her and, if not settling either repeat or perform spirometry.

8. Arthur – an 80 year old Type 11 diabetic has tightness in his chest which occurs on walking 100 yards on the flat or on emotion – especially after eating. He has not experienced the pain at rest and when he stops it settles after 5-6 minutes

A. Reassure and do nothing
B. Dial 999 for emergency ambulance
C. Check the D Dimer
D. Check Troponin T
E. Prescribe Aspirin 75mg daily
F. Send for a chest x-ray
G. Prescribe an antacid
H. Arrange an abdominal ultrasound scan
I. Refer to the Rapid access chest pain clinic

Answer: I

Arthur (case 8) probably has chronic stable angina and should be referred to the Rapid Access Chest pain clinic. Age is not a bar to effective treatment and, while he is waiting it would be sensible to check his lipids,Hb and electrolytes as well as a resting ECG .It would be reasonable to commence symptomatic treatment (eg Nitrate) as well as commencing Aspirin and a Statin – if not already taking them.



A 60 year old man has an anterior myocardial infarction treated acutely by Percutaneous Intervention (PCI) with stents and made an uneventful recovery.

9.
Which one of the following statements is true: [Show Discussion]

A. Aspirin needs to be given for 5 years and then stopped
B. Clopidogrel should be given for a year.
C. He should not be given ACE inhibitors if his creatinine is over 120mmol/l
D. He only needs a statin if his total cholesterol is more than 5.0 mmol/l
E. He doesn’t need a B Blocker unless he has a pulse persistently greater than 80

Answer: B

Current recommendations are that with stents clopidogrel continues for a year. Some cardiologists would advocate longer – but the evidence is not yet available. This is a fast moving field! Aspirin, B Blockers , statins (whatever the cholesterol)and possibly ACEI should be permanent. He needs his creatinine monitoring carefully.