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INSTRUCTIONS FOR THE DOCTOR

This is a short case.

Please take a history from Jackie. Ask for the results of a focused examination from the facilitator. Tell Jackie the most likely diagnosis and your management plan.

Scenario

Jackie Maloney is a 50-year-old taxi driver. She smokes 30 cigarettes a day. She has asked for an appointment to see you today because she has noticed some pain in her chest when she lifts heavy suitcases or has to go up stairs.

The following information is on her summary sheet:

  • Past medical history

  • Mechanical low back pain—recurrent

  • Hiatus hernia—gastro-oesophageal reflux disease

  • Medication

  • Omeprazole 40 mg od

  • Allergies

  • Nil

  • Immunisations

  • Nil known

  • Family history

  • Irish family

  • Mother died of myocardial infarction aged 60

  • Social history

  • Taxi driver.

INSTRUCTIONS FOR THE PATIENT, JACKIE MALONEY

You are a 50-year-old taxi driver. You feel heaviness in your chest on exercise. The heaviness lasts for less than a minute if you stop what you are doing. You are worried that this heaviness comes from your heart. It has been getting worse and you have finally admitted that you need help. At the back of your mind is the fact that your mother died of a heart attack. You have not had any palpitations but when pressed admit that you have some shortness of breath at the same time as you get the chest pain. You last had pain two days ago.

The most likely diagnosis is angina.

The following information is on your summary sheet:

  • Past medical history

  • Mechanical low back pain—recurrent

  • Hiatus hernia—gastro-oesophageal reflux disease

  • Medication

  • Omeprazole 40 mg od

  • Allergies

  • Nil

  • Immunisations

  • Nil known

  • Family history

  • Irish family

  • Mother died of myocardial infarction aged 60

  • Social history

  • Taxi driver.

INSTRUCTIONS FOR THE FACILITATOR

Clinical examination findings

  • Looks well

  • No cyanosis

  • Height 1.65 m

  • Weight 87 kg

  • BMI 32 kg/m2

  • Waist circumference 94 cm

  • Blood pressure 130/80 mmHg

  • Pulse 72

  • Apex beat not displaced

  • Heart sounds normal, no added sounds

  • Chest clear

  • Peripheral pulses present, no oedema.

Please have a copy of Assessing Fitness to Drive available and pass to the candidate on request. Please keep the copy out of sight until requested.

SUGGESTED APPROACH TO THE CASE

Establish rapport

Open questions to explore patient’s ideas, concerns and expectations.

Specific questions

Detail about the heaviness/pain

Shortness of breath

Palpitations

Cough

  • — Relieving factors

Assess cardiac risk factors

  • — Smoking

  • — Diabetes

  • — Hypertension

  • — Hyperlipidaemia

  • — Family history

Explore lifestyle contributing factors, diet and exercise

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