History - Quiz Chest Pain

The most failed station according to a PACES book is Station 2 - History because it is the least practiced for the exam station. We were discussing about this a moment ago.

Scenario : Mdm Ma is a 40 years old Malay lady who has been diagnosed hypertension and is currently on T. Metoprolol 25 mg bd. The GP has referred this case as this lady has been complaining of chest pain for the past 6 weeks.

Kindly take a history from this patient.

Based on the history,

This lady had the following characteristics of chest pain - crushing, radiating to the back, lasting for 5 minutes, at rest, almost everyday, not related to meals or respiration. No DM, Stroke. Strong family history of IHD - Father IHD at 60 y.o, Brother IHD - passed away at 45y.o and grandmother IHD at 71 years old. Non-smoker, no alcohol consumption. Works as a clerk, married with 4 children.

This is the very brief history.

Questions

1. What are the provisional diagnosis in this case ?
2. What is the differential diagnosis in this case and so with the differential diagnosis, and what are the further questions you would like to ask ?
3. What investigations and plan ?

"History Taking"

MRCP-PACES 30th November 2005

Station 2:
History Taking:
Scenario:
Letter from GP; 33 years old Malay lady presented with complaint of shortness of breath of three weeks duration associated with fever, cough and pleuritic chest pain. Chest x-ray reviewed a left-sided pleural effusion. Kindly see her for further management.

I started by taking a usual history regarding the history of presenting illness, with questions targeting more on the differential diagnosis of pleural effusion. Nothing much in the past medical history, no allergy, only child, no significant family history. A secretary in a law firm, cigarette smoker, regular alcohol once a week, has a fiance but no sexual relationship. Only concern was patient has shortness of breath and was unable to climb stair case to her 2nd floor apartment (no lift). Surprisingly, she did not have any other social problem or concern. Examiners asked the usual questions like, differential diagnosis of pleural effusion, investigation and general magagement.

Commment:
This case was quite relatively straight forward. Luckily, patient was quite cooperative and there wasn't much concern from her. Questions asked were quite direct. The only thing I feel was, probably I could have asked about some differential diagnosis of shortness of breath too. The case might not just be pleural effusion as diagnosed by the GP. Perhaps, one should think broadly.

Outcome: 3/3