8 stations / 107 steps/ 65 script lines
History taking
Work each station top to bottom and tick as you go; the quoted lines are phrasings you can use word for word. Hide the lines to recall them first, or take any station to the Drill Room and run it against the clock.
0 of 107 steps
0/6Set-up
- Introduce yourself, your role, and the nature of the interview; re-obtain consent.
- Mention note-taking“I will be taking notes throughout our session to record details, so I may be looking down now and then.”
- Mention confidentiality“What we discuss today will be kept confidential within the clinical team, which means I will share my notes with my preceptor and the healthcare providers involved in your care.”
- Name and age“How might I best address you? How old are you? Who did you bring with you today?”
- Chief complaint“What brings you in today? What would you like to talk about today? Can you tell me more about that? What do you mean by X?”
- In a psychiatric interview, also ask about the patient's understanding of the reason for the interview.
6 steps left in this station.
Chest pain
Ten causes by the pain itself, what travels with it, and the examination and first tests that separate them.
| Row | Pain | Associated features and risk | Examination and first tests |
|---|---|---|---|
| Acute coronary syndrome | Central crushing pressure or tightness radiating to the arm, jaw or back, building over minutes and lasting more than 20 minutes at rest, or exertional and now worse; in older adults, women and diabetics it can be breathlessness or epigastric discomfort | Sweating, nausea, breathlessness; age, smoking, diabetes, hypertension, lipids, family history, known coronary disease | Often normal; a fourth heart sound, crackles or hypotension when it is not; ECG within 10 minutes and repeated, high-sensitivity troponin at presentation and again at 1 to 3 hours |
| Aortic dissection | Abrupt tearing or ripping pain, maximal at onset, in the front of the chest moving to between the shoulder blades or downward as it extends | Hypertension, Marfan or Ehlers-Danlos syndrome, a bicuspid valve, cocaine, pregnancy; syncope, a stroke or a cold limb from branch involvement | A pulse or pressure difference between the arms, a new early diastolic murmur, a widened mediastinum on the film; CT angiography, and no anticoagulation until it is excluded |
| Pulmonary embolism | Sudden pleuritic pain with breathlessness, or breathlessness alone; central and dull with a large clot | Hemoptysis, syncope, a swollen leg; immobility, surgery, cancer, estrogen, pregnancy, a previous clot | Tachycardia, tachypnea, low saturation, a loud pulmonary second sound, a swollen calf; Wells score, D-dimer when the probability is low, CT pulmonary angiogram otherwise; the ECG most often shows only sinus tachycardia |
| Pericarditis | Sharp central pain, worse lying flat and on inspiration, relieved sitting forward, over hours to days | A recent viral illness, a heart attack in the past weeks, kidney failure, autoimmune disease | A scratchy rub best heard leaning forward; ECG with widespread saddle-shaped ST elevation and PR depression; echocardiogram for an effusion |
| Pneumothorax | Sudden one-sided pleuritic pain with breathlessness | A tall thin young man, a smoker, asthma or COPD, a recent procedure or trauma; distress, falling saturations and a shifted trachea mean tension | Reduced breath sounds and hyperresonance on the affected side; chest film, or immediate decompression if tension is suspected clinically |
| Pneumonia and pleurisy | Localized sharp pain with breathing and coughing, over a day or two | Fever, productive cough, rigors, breathlessness; a recent viral illness, aspiration risk | Fever, crackles, bronchial breathing and dullness over the area; chest film, CRP and cultures; CURB-65 to decide on admission |
| Esophageal reflux and spasm | Burning behind the sternum after meals, lying flat or bending, or a squeezing pain with swallowing that mimics angina, minutes to hours | Acid taste, dysphagia, relief with antacids; obesity, alcohol, late meals; a normal cardiac work-up | Normal examination; a proton pump inhibitor once the heart has been excluded, endoscopy for alarm features (dysphagia, weight loss, bleeding) |
| Costochondritis | Sharp localized anterior pain, worse with movement, deep breaths and pressing on the spot, lasting days to weeks | Recent exertion, coughing or a new activity; no exertional pattern | Reproducible tenderness over the costochondral junctions with a normal ECG; reassurance and anti-inflammatories |
| Panic attack | Sudden intense fear with chest tightness peaking within minutes and passing within half an hour, often recurrent in the same situations | Palpitations, tingling of the lips and fingers, a sense of doom, hyperventilation; previous anxiety; young with no cardiac risk | Normal examination once settled and a normal ECG; a diagnosis made after the dangerous causes are excluded, never instead of excluding them |
| Herpes zoster | Burning or stabbing pain in one dermatomal band around the chest, present for days before any rash | Older or immunosuppressed; tingling and sensitivity to touch in the band | A vesicular rash in the dermatome confirms it; before the rash the examination is normal; antivirals within 72 hours of the rash |
Recall quiz
Sort the chest pain
The pain and what travels with it in; the cause out.
Score 0 / 10Streak 0
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