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You are the F2 working in the ambulatory care unit of your local hospital. The next patient to see is a 19yr old girl called Elle Pee. She has been referred in by her GP complaining of chest pain. The GP summary lists migraines in her past medical problems, and she is prescribed Sumatriptan 50mg PRN, and the combined oral contraceptive pill ‘Yasmin’. Please take a focussed history of her presenting complaint and perform a relevant examination.

You are Elle Pee, a 19 year old girl who has been referred to the ambulatory care unit with chest pain. HPC: The pain started yesterday, and came on suddenly while exercising. It is a sharp stabbing pain on the left hand side of your chest, that doesn’t go anywhere else. It makes you feel short of breath, but when you try to take a deep breath the pain gets worse. If you had to score it out of 10, it’s a 4 but goes up to a 7 when you take a deep breath. You feel like your heart is racing, and it makes you feel a bit light headed. Your symptoms are a bit better when you relax and lie down, but its never really gone away. You haven’t had a cough, fevers or been sick. You’ve never had anything like this before. Up until yesterday you were feeling absolutely fine physically. You have been feeling a lot more stressed recently about your upcoming move away to Birmingham for university, particularly around money. You’ve been going to the gym a lot more because it helps you relax, and you have recently started ‘Cross Fit’ classes. If asked directly: you recently came back from a girl’s holiday in Turkey where you celebrated your sister’s 18th birthday. The flight was 5 hours long. Since then you’ve had some cramp in your left calf, but you hadn’t given it much thought. You’ve had no recent surgeries, and have never previously had a blood clot in your legs or chest. PMH: You’re normally fit and well, other than suffering from migraines which seem to be triggered by stress and chocolate (how unfair is that!). You’ve never been in hospital before. Medication: You have no allergies. You take no medications other than the Yasmin contraceptive pill, and occasional Sumatriptan when your migraines are bad. SH: You live with your mother and two sisters, but are moving to Birmingham to study Marine Biology next September. You smoke around 5 cigarettes a day. You usually drink around a bottle of wine and a few gins each week, but that was a lot heaver when you were away in Turkey. You don’t do any drugs. You currently work at Superdrug. ICE: You don’t know what’s causing the pain, but are worried its from your heart or maybe an infection you picked up in Turkey? You were hoping to get something to make the pain settle.

Please observe the student taking the history. Performing either a respiratory or cardiac examination would be entirely appropriate. The positive findings would be a fast, regular, pulse rate of around 110 bpm. The chest is clear and heart sounds normal. Tender left calf to palpation with no swelling or erythema. The history of pleuritic chest pain with recent long haul flight and COCP use should prompt the students to think of a PE as an important differential. MSK chest pain or anxieties are also sensible differentials. Questions you could consider asking the student are: • What is the classic triad of symptoms in a pulmonary embolus (PE)? • Do you know any scoring systems to risk stratify patients with potential PEs? • What are the risk factors in the patient for PE? • What are the treatment options for PE, and what are the pros and cons of each? • What are the indications for thrombolysis? • What is the relevance of her contraceptive to the case? Should she continue it? What might be a suitable alternative?