Download www.osce-aid.co.uk clinical skills: explaining the diagnosis of

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clinical skills: explaining the diagnosis of angina
Possible OSCE scenario:
A 69 year old patient has been seeing you in your surgery regarding central chest pain
occurring on exertion. Your referred him to the local Rapid Access Chest Pain Clinic where
they have carried out a series of investigations. The cardiologists there have made a
provisional diagnosis of angina secondary to coronary artery disease.
He has come to see you to discuss the diagnosis. Please answer any questions he may have.
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Wash your hands
Introduce yourself
Ask patient's name
Ask permission to discuss his diagnosis
Ask him what he understands of the diagnosis and its management. You can then use this to
guide your discussion.
Examples of what to discuss are included below.
What is angina?
 Angina is refers to the symptom of chest pain. The pain felt because there isn't enough blood
getting to the heart muscle, straining it. This is usually caused by blockage of the vessels
around the heart
 This pain may occur during exercise only or at rest
 It can be associated with shortness of breath, sweating or dizziness.
 It significantly increases your risk of having a heart attack, where the blood supply is
critically cut off to the heart. It is therefore important to treat angina early.
 It is relatively common, occurring in 2% of the population in the UK
What causes angina?
 The cause of angina is multifactorial. You may have many or none of the following.
 It is more frequent in people who smoke, have high blood pressure, diabetes and high
cholesterol levels
 It is more likely if there is a family history of angina, and in people of certain ethnicity
How do you diagnose angina?
 Angina can be diagnosed by various tests.
 These include non-invasive tests such as exercise ECGs, echocardiograms and MRIs.
 You may have a more invasive test called an angiogram if appropriate to you.
 These tests will be explained to you in further detail if and when you need them.
How do you manage angina?
 There are many different means for managing angina, specifically via support and education,
lifestyle changes and medication.
 Support and education:
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◦ I will provide you with a leaflet on the available services and charities
Lifestyle changes:
▪ Stopping smoking
▪ Reducing alcohol intake
▪ Exercising
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 Light exercise only at first
 Losing weight
▪ Changing your diet
 Less fatty foods and more fibre
 I can refer you to our dietician if you feel this would be useful
◦ Informing the DVLA
▪ If you do not drive for a living, you do not have to tell the DVLA but must tell your car
insurance company
▪ You will have to inform the DVLA that you have angina if you drive for a living
 You must be have no symptoms for 6 weeks and pass an exercise ECG test to continue
Medication:
▪ Aspirin
 This acts to make the blood thinner so future blockages of the vessels are less likely to
occur
 Side effects: indigestion which we can treat if it occurs
▪ Statins
 This drug aims to reduce the cholesterol in your blood, again making future blockages
less likely to occur
 Side effects: liver enzyme changes (we will monitor for this) and muscle pain (please
consult a doctor if this occurs)
▪ GTN spray will help to control symptoms
 This acts to increase the diametre of the vessels around the heart, which allows enough
blood to pass through it
 You put this under your tongue whenever you feel chest pain. Should work within a few
minutes – if not, can take a second dose. If this does not work after 15 minutes, call your
doctor.
 Side effects: headache, dizziness
▪ Beta blockers
◦ These reduce the amount that the heart has to work during periods of exertion, e.g.:
on exercise. Therefore less oxygen is needed by the heart, so your symptoms lessen
◦ Side effects include:
▪ Coldness of hands and feet
▪ Poor sleep and tiredness
▪ Impotence (rarely)
▪ Other medications may include:
 calcium channel blockers
 isosorbide mononitrate
 Nicorandil
▪ Control of other conditions for example diabetes and high blood pressure
◦ Surgery such as grafting or stenting is also an option if these treatments do not help
◦ It is important to take these medications every day in order to reduce the risk of a heart attack
We will also see you regularly to monitor how you are getting on and to monitor your symptoms
Check understanding of the above
Have you got any questions?
Thank patient and provide with a leaflet