Student Instructions
You are a junior doctor working in the Accident & Emergency Department.
Mrs Nadine Bieber is a middle-aged lady who has come into the department with her daughter complaining of feeling nauseated, dizzy and generally ‘not right’.
Please take a focussed history from her and suggest a differential diagnosis.
The examiner will stop you at 7 minutes to ask you a few questions.
Patient Instructions
Name: Mrs Nadine Bieber
Age: 56 years old
Job: Unemployed
PC
You were out and about in town this afternoon with your daughter shopping for clothes to wear to your best friend’s birthday party this weekend when you suddenly came over all ‘funny’.
You say that almost out of the blue you felt sweaty and clammy and knew you needed to sit down.
When you found a bench in the shop to sit on you felt very nauseated and dizzy like everything was spinning.
Your daughter says you looked very pale and that she noticed you panting to catch your breath.
The whole episode lasted about 5 minutes and afterwards you just felt very sleepy and drained.
You did not have any chest pains during the episode and deny being sick although you desperately thought you were going to be.
You have not had any similar episodes before. You deny palpitations, neurological symptoms or any shortness of breath.
At the moment all you want to do is lie down and have a nap.
Your daughter was very worried and thought coming to the hospital first would be a better idea than continuing to go shopping or sleeping at home.
In the last month you have been feeling fine and did not suffer from any colds, flues or coughs. You have not had any contact with anyone suffering from infections and have not travelled abroad. You have not lost weight or had any change in your appetite or bowel habits. You do not suffer from orthopnoea and sleep with one pillow at night. You never wake up in the middle of night and you are a deep sleeper.
PMH
T2DM- your diabetes is poorly controlled and your last HbA1c a month ago was 11%. Your BMs are always erratic and so you don’t really bother to check them as you don’t really understand what to do about them- (do not admit this to the doctor unless specifically asked)
HTN
Hypercholesterolaemia
Laser therapy to retinas several time for diabetic retinopathy
Gout
You deny ever having any cardiac investigations or a previous heart attack
DH
NKDA
Metformin 500mg po bd
Doxazocin 2mg po od
Pravastatin 40mg po od
Allopurinol 300mg po od
SH
You have smoked 20 cigarettes a day for the last 10 years. You drink about 3 glasses of wine a week, mostly during the weekends at mealtimes with your friends and family. You do not take any recreational drugs.
You are divorced and life in your own small one bed roomed apartment. You have one daughter who is 30 years old and works in a bakery. You do not work and spend most of your days either visiting your daughter or meeting up with your friends.
FH
Your father died at the age of 58 years old after a sudden severe brain haemorrhage.
Your mother and aunt both suffered with T2DM when they were in their 50s.
ICE
You think that this funny episode was all due to a mini-stroke and you worry that it may only be a matter of time before you experience a full-blown stroke and die in the same way your father did!
Questions
What is the likely diagnosis?
Silent myocardial infarct
What are your differentials?
Vasovagal syncope
Panic attack
Viral flu
Angina
What investigations would you do?
Immediate investigations include:
- Blood tests- FBC, U&E, LFTs, glucose, lipids, clotting screen, serial troponins
- ECG to look for ST segment changes
- CXR
- Referral for coronary angiogram with or without angioplasty (in some centres, thrombolysis may be an alternative consideration)
What would your immediate medical management include?
Oxygen- high flow
Analgesia- 5-10mg morphine with an antiemetic
Aspirin- 300mg po stat
GTN- sublingual
Heparin SC injections (e.g. enoxaparin 1mg/kg every 12 hours SC injections after an initial loading dose of 30mg bolus administered IV)