Mock 11

Patient Prompts

• Onset: "The pain started suddenly about an hour ago."
• Duration: "It's been constant since it started."
• Progression: "It seems to be getting worse."
• Aggravating Factors: "Nothing makes it better or worse; it's just there all the time."
• Relieving Factors: "I haven’t found anything that relieves the pain."
• Past Medical History: Hypertension.
• Regular Medications: Occasionally takes antihypertensive medication.
• Allergies: No known drug allergies.
• Smoking and Alcohol Intake: Smokes a pack a day, occasional alcohol.
• Use of Recreational Drugs: Denies use.
• Occupational History: Works as a financial analyst.
• Simulated Examination Findings: Blood pressure 180/110 mmHg, pulse 98 bpm, asymmetrical blood pressure readings between arms, pain described as tearing/ripping in nature, radiating to the back.

Scenario Clinchers

• Patient Concerns: Extremely worried about the pain and its severity, anxious about the potential causes.
• Clinchers and Important Points for the Doctors: The description of the pain, high blood pressure, and the patient's medical history are highly indicative of an aortic dissection.

What You Must Do:

• Immediate Actions:
  • Administer IV antihypertensives to reduce blood pressure and the mechanical stress on the aorta (e.g., beta-blockers like esmolol).
  • Provide pain management with appropriate analgesics.
  • Initiate continuous monitoring of vital signs and cardiac rhythm.
• Diagnostic Steps:
  • Order a CT angiogram of the chest to confirm the diagnosis of aortic dissection.
  • Consider an echocardiogram to assess cardiac function and any involvement of the aortic valve.
• Preparation for Intervention:
  • Alert cardiothoracic surgery for potential surgical intervention.
  • Prepare for possible transfer to a facility equipped for emergency cardiovascular surgery if not available on-site.

Differential Diagnosis

• Aortic dissection
• Myocardial infarction
• Pericarditis
• Pulmonary embolism

Typical Question to Rule Out Differentials: "Does the pain change with breathing or body position? Have you experienced any symptoms like shortness of breath, palpitations, or fainting?"

Red Flags

• Sudden onset of severe chest pain with a ripping or tearing sensation
• Difference in blood pressure between arms
• Signs of shock or cardiac tamponade (hypotension, muffled heart sounds, distended neck veins)

Actions Doctor Should Do

• Administer medications and manage pain as outlined above.
• Perform necessary diagnostics urgently.
• Prepare for immediate surgical consultation and potential intervention.

Referral Needs

• Type of Referral: Immediate referral to a cardiothoracic surgeon.
• Reason for Referral: Surgical evaluation and management are critical for survival in aortic dissection, necessitating urgent specialist involvement.

This revision ensures that all aspects of emergency management of a suspected aortic dissection are clear, providing a detailed plan for initial assessment, immediate management, diagnostics, and referral.