• Candidate Instructions
  • Actor Instructions
  • Mark Sheet
  • Score

Location: You are an FY1 on medical ward cover. The ward sister has bleeped you to see a patient

Patient: 55 year old man has developed central crushing chest pain

Task:
– Take a focused history from the patient
– Perform a full ACDE assessment, a nurse will be available to help you with investigations or management that you require.
– After 6 minuets you will be asked a series of questions by the examiner.
– Answer any questions that the patient may have

Note to actor: Try to restrain yourself from volunteering to much information – you may do so when prompted (that is, by a specific question, not a general one). If a student is on the wrong line of clinical reasoning do not fuel this line of thinking, state no to the question as being ambiguous may prompt further questioning and does not allow the student to be appropriately tested. The aim of the exercise is to take a focused history; short answers are required.

Central crushing chest pain came on 1 hour ago. Pain is a 10/10, radiates to jaw and  left shoulder. You have not experienced anything like this before. You feel sweaty and terrible like you are going to die. You have vomited once and feel incredibly nauseous.

PMH = hypertension, type 1 diabetes

DH = novorapid, levemir insulin

No known drug allergies

Category Question
Done
Excellent
Introduction Candidate appropriately introduced themselves with:
Full name
Medical school, year or grade
Clarifies who they are talking to
Asks patient for preferred name


History History
Ascertains central rushing chest pain
Radiation to left shoulder
PMH: hypertension, type 1 diabetes
DH: KNDA, insulin regime clarified


Airway assessment Airway assessment
Patient talking
Airway patent


Breathing assessment Breathing assessment
Oxygen saturation = 89% on room air
Respiratory rate = 30
Position of trachea = central
Chest expansion = equal
Chest sounds = clear


Breathing investigations Breathing investigations
Requests ABG
CXR


Breathing treatment Breathing treatment
Oxygen 15L through non-rebreathing mask


Circulation assessment Circulation assessment
Patient sweaty / clammy
Blood pressure – 170/85 mmHg
Heart rate – 100/min
Peripheral and central cap refill – < 2 seconds
Heart sounds = I + II + 0


Circulation investigations Circulation investigations
2 large bore IV cannulae
Bloods = FBC, U&E, CRP, trop, HbA1c
ECG


ECG
ECG interpretation

ST elevation in anterolateral leads (mainly V1-V4)
Q waves in septal leads (V1-2)
Peaked T waves in V2-4


Diagnosis Diagnosis
Candidate confirms anteroseptal STEMI


Treatment STEMI treatment
Analgesia: Morphine 5-10mg IV titrated to pain
Antiemetic e.g IV Cyclizine 50mg IV STAT
Aspirin 300mg PO STAT
Clopidogrel 300mg PO STAT
O2 admistered (e.g 2-3L/minute for at least 2-3 hours)
Primary PCI or Thrombolysis


Circulation treatment Circulation treatment
500ml of 0.9% normal saline STAT


Disability assessment Disability assessment
Blood glucose
Temperature
A on AVPU
Pupils equal and reactive to light


Exposure Exposure
Candidate adequately exposes patient


Escalation Escalation
Candidate offers to call / bleep medical registrar


Reassessment Reassessment
Candidate offers to reassess in an ABCDE approach



Score