Stable Angina

Casebank History
1

Where are you:
FY2 in GP Surgery

Who the patient is:
James Brown, a 65-year old man came to the practice with chest pain.

Other information you have about the patient:
None

What you must do:
Talk to the patient, take a history and discuss initial management.

Patient Information:

  • Your name is James Brown. You are a 65-year-old man.
  • Your wife asked you to go and get checked for chest pain.
  • The pain is behind the breast bone and it radiates to the jaw. It is dull pain.
  • Pain does not radiate anywhere else.
  • It’s usually worse when walking uphill or exercising but goes away on resting.
  • He usually climbs uphill while going to buy bread every day. This is when you get the chest pain. The pain goes away when you rest on the bench. You also smoke while going to the shop.
  • You smoke 20 cigarettes a day since he was a teenager. He has never tried to cut it down but he is willing to stop smoking.
  • Your diet consists of fast food as you go out a lot with your wife (OR you eat 5 portions of fruit every day, you eat meat and vegetables, your wife cooks at home and looks after you).
  • You believe that your diet is healthy. Drinks 1 whiskey shot every night to help him sleep.
  • My wife was worried about this; I just think it’s just a normal chest pain that’s it really.
  • No other significant past medical history.
  • Patient is cooperative in nature. You do not exercise.
  • You sit down the whole day watching TV.
  • Your father died of heart attack when he was 60 years old.
  • You don’t have any siblings; you are the only child in the family.
  • Your mother is alive and healthy.

Data Gathering

Introduction & confirm the identity of the patient

HISTORY & DIFFERENTIALS

  • SOCRATIS for pain
  • are you in pain now ? Offer analgesics…

Differential Diagnosis

  • Myocardial infarction - Do you have central chest pain? Does it radiate? - Do you have nausea or sweating?
  • Pulmonary embolism - Any shortness of breath? - Have you been on long flight? Or had any operation recently? Or been immobile recently?
  • Pericarditis - Have you been feeling feverish? - Does the pain improve on leaning forward?
  • Trauma - Did you sustain any injury to the chest recently?
  • Aneurysm - Does the pain radiate to the back?
  • Shingles - Did you notice any rash, particularly in the back coming to the front? - If yes, is it itchy, painful, spreading, what side, the first time having a rash?

Risk factors for MI :

  • Smoking - DM - HTN - Family History - Previous IHD - High Cholesterol
  • Family hx of heart problems ?
  • Have you sustained any kind of trauma recently?
  • Have you been doing any kind of heavy exercised recently?

Others

  • FLAWS
  • MMA questions
  • DESA
    • Diet and smoking
  • ICE & PSYCHOSOCIAL
    • Has this affected you in any way?
    • Has the chest pain affected your daily activity?
    • Has the chest pain affected your sleep?
    • Do you have stairs at home? How many?
    • Are you able to climb up and down the stairs briskly without developing any chest pain?
    • I need to ask you a personal question,
    • Are you sexually active? - Has the chest pain affected your sexual life? -
    • Do you ever get chest pain during sexual intercourse?

EXAMINATION

  • Vitals + relevant ex chest + ECG + BMI + chest xray + + heart attack markers

DIAGNOSIS

  • Thank you for letting me examining you From what you’ve told me and after examining you(explain +ve findings), I suspect you are having a condition called stable angina It is chest pain that happens during activity due to lack of blood supply to heart muscle

Management

  • Routine blood tests + lipid profile
  • we need to do an ambulatory ECG (Electrocardiogram), which is a tracing of your heart electricity and it tells us how your heart is doing
  • We’ll start you on Glyceryl trinitrate (GTN) mouth spray to use if you get a chest pain to relieve it. And Aspirin 75mg once daily, it is a blood thinner tablet to help blood flow untill diagnosis is confirmed. If aspirin is contraindicated (stroke/allergy/PAD) give clopidogrel
    instead
  • I will refer you routinely to the cardiologist to confirm the diagnosis of stable angina.
  • They may Prescribe a beta-blocker or a calcium-channel blocker (CCB) as first-line regular treatment to reduce the symptoms of stable angina
  • It is advisable to stop driving until you see the cardiologist and the diagnosis can be confirmed.
  • There are also certain things you can do for yourself to protect your heart and prevent any upcoming heart attacks; • It is advisable to lose weight and have healthy food. So, I can refer you to a dietician to help you lose weight and maintain a healthy balanced diet.
  • It is also advisable to reduce alcohol to < 14 units per week with at least 2 alcohol free days and smoking cessation.
  • If you get a chest pain when you walk uphill, you can take the GTN before walking uphill, which would help preventing the attack.
  • If symptoms are occurring at rest then, seek immediate medical care and it is advisable that you stop driving and inform the DVLA if driving lorries/buses, however if driving cars or motorcycles it is their responsibility.
  • Regarding work, it is fine as long as it is not including heavy activities.
  • If you can walk up 2 flights of stairs briskly without developing a chest pain, then sexual activity is unlikely to precipitate an episode of angina.
  • But if sexual activity precipitates an episode of angina, so you can take GTN before intercourse. However, if you use Viagra (Sildenafil) you should avoid using GTN for at least 24 hours before or after taking Viagra. It can be life threatening if you combined both medications.
  • follow up in one week
  • SAFETY NETTING
  • LEAFLET