Steven is a 48-year-old man who came to the clinic with a [[“chief complaint”]] of chest pain. Steven had been seen several times before in the clinic for his high blood pressure.
He is an interesting guy – very humorous and loves to talk to me about his 3 rambunctious children (whom also are patients) and his job as the CEO of his father’s asphalt company. When the economy took a dive, Steven started to feel the pressure at work. He’s been putting in long hours. And when he goes to bed, his mind really starts to wander and that’s when he feels the stress and subsequent [chest pain.]<chest|
(click: ?chest)[Steven reveals that he has been experiencing this chest pain for the last 2 weeks, only at nights when trying to go to sleep. The pain feels like an “ache” right in the middle of his chest, and typically lasts 30 minutes or so. It is moderate in severity, and does not radiate to anywhere else in his body. He humorously adds that his pain seems to magically resolve after taking a few sips of his morning coffee.
Should you take a few moments to review Steven's past history?
[[yes|Past History Steven]]
[[no|Steven home]]]
This game is designed to take you through the process of feeling ill - in this case with chest pain - and to think about how doctors consider the complaints of the patient, in their decisions. What tests they might suggest. If they treat men differently than women.
[[Note for use in classroom]]
The goal is to tests your decision making, to think about what kind of information can reveal about a persons health, as well as give insight into the complexity of diagnosis.
To begin, pick one of the people below to and follow them through the following senario:
[[Steven]] 48, hardworking family man who runs his family business.
[[Sarah]] 49, single, and a hardworking nurse working at a nursing home.
[[Mrs. Sterling]] 69, a former nurse and mother of a 28 year old son.
****PLEASE NOTE THIS IS A WORK IN PROGRESS****Past History: Steven is overweight, as he doesn’t make much time for exercise and tends to eat on the go. As a result, he was diagnosed with high blood pressure several years ago, but has been able to control it with a medication that he takes once a day. Other than that, he’s a pretty healthy guy. However, heart disease seems to run in his family and his own father died from a heart attack 10 years ago, leaving him the responsibilities of the business.
Considering his current complaints and his past history what do you [suggest?]<Ask|
(click:?Ask)[Ask Steven more [[questions]] about his daily life to get a better understanding.
OR
Send [[Steven home]] and tell him to take a vacation and eat better?
OR
Send him to the [[hospital]] for some tests?][[Mystery diagnosis revealed]]Sarah reveals that for a couple months she has been having night sweats, which come after abuptely waking. But not every night. In addition she has recently felt under the weather. But she keeps coming back to the fact that she has been putting in extra hours at her job, which include long-nights and early mornings. She feels that this is making her tired and feeling off her game. She thinks that once she has her vacation she will be much better.
Sarah also used to be a heavy smoker, and in the last 5-years traded her smoking habit for yoga, which she finds keeps her centered. She also has been walking a lot after getting a dog. Her family history presents no red-flags, both her parents are living and healthy. But her panels from her physical last year reveals high cholesterol, and she has put on about 20 lbs since then as well.
Considering her current complaints and her past history what do you [suggest?]<Send|
(click: ?Send)[Send [[Sarah home]] and tell her to get some rest and eat better?
OR
Send her to the [[hospital ]] for some tests?
Ask Sarah more [[questions ]] about her daily life to get a better understanding.]
Brief explanation of testing options
ECG or EKG : An electrocardiogram records the electrical signals in your heart. It's a common test used to detect heart problems and monitor the heart's status in many situations. Electrocardiograms — also called ECGs or EKGs — are often done in a doctor's office, a clinic or a hospital room. And they've become standard equipment in operating rooms and ambulances.
blood test : Blood tests. Certain heart enzymes slowly leak out into your blood if your heart has been damaged by a heart attack. Doctors will take samples of your blood to test for the presence of these enzymes.
Stress tests : A stress test, also called an exercise stress test, gathers information about how your heart works during physical activity. Because exercise makes your heart pump harder and faster than usual, an exercise stress test can reveal problems within your heart that might not be noticeable otherwise. Your doctor may recommend an exercise stress test if they suspect you have coronary artery disease or an irregular heart rhythm (arrhythmia). The test may also be used to guide your treatment if you've already been diagnosed with a heart condition.
Chest x-ray : If you go to your doctor or the emergency room with chest pain, a chest injury or shortness of breath, you will typically get a chest X-ray. The image helps your doctor determine whether you have heart problems, a collapsed lung, pneumonia, broken ribs, emphysema, cancer or any of several other conditions. The chest X-ray is a common way to diagnose disease. But it can also be used to tell whether a certain treatment is working. Some people have a series of chest X-rays done over time, to track whether a health problem is getting better or worse.
Ultrasound : (transthoracic echocardiogram;TTE; echocardiogram; echo) Provides your doctor with moving images of your heart and takes excellent pictures that will help your doctor evaluate your heart health. The most common type of heart ultrasound is non-invasive and very easy on the patient. A specially trained technician, called a cardiac sonographer, uses a gel to slide a microphone-like device called a transducer over the chest area. This allows reflected sound waves to provide a live picture of your heart and valves. Heart Ultrasound uses the same technology that allows doctors to see an unborn baby inside a pregnant mother. No radiation is involved in heart ultrasound, and the technology can be used on people of all ages.
Return to [[hospital]] and decide which tests you will run.
Deciding what [[tests]] to run on a patient depends on many factors – their age, their personal medical history, their history of present illness, their family history, their vital signs in clinic (blood pressure, pulse, weight, oxygenation level, etc.), and the results of the physical exam.
So you can see that it takes a good deal of information gathering, before deciding on what tests to run.
Depending on the information available, doctors may run the following tests in a case like this which tests would you [run]<run|?
[[ECG or EKG]]
[[blood test]]
[[stress tests]]
[[chest x-ray]]
[[ultrasound]]
Sarah is a 49-year old, a nurse who came to the clinic with her [[“chief complaint”]] as a really bad pain near her collarbone and neck, spreading into her jaw. Sarah had no other complaints and even shared that she usually kept fit, by doing a lot of walking with her dog and yoga two or three times a week - although recently this has not been as easy to fit into her daily schedule. She also said she normally ate well. But lately she was also super tired. All of these things she blames on the recent increase in hours at her work as a care-giver and nurse at the nursing home, which has been very busy. She assumes that this is adding to her [fatigue.]<Should|
(click:?Should)Should you take a few moments to review Sarah's past history?
[[yes|past history Sarah]]
[[no|Sarah home]]]Blood tests. Certain heart enzymes slowly leak out into your blood if your heart has been damaged by a heart attack. Doctors will take samples of your blood to test for the presence of these enzymes.
For Steven this means a quick draw of blood.
(click:?results)[RESULTS: NORMAL HEART
Return to [[hospital]] for a different test. Or go directly to another test:
[[ultrasound]]
[[chest x-ray]]
[[ECG or EKG]]
[[stress tests]]
Or goto: [[Summary of all Steven's test results]].]For Steven a stress test, also called an exercise stress test, gathers information about how his heart is working during physical activity. E
Exercise makes your heart pump harder and faster than usual, an exercise stress test can reveal problems within your heart that might not be noticeable otherwise.
The doctor has Steven walk on a treadmill (sometimes they have the patiend ride a stationary bike) while his heart rhythm, blood pressure, and breathing are monitored.
(click:?results)[RESULTS: NORMAL HEART
Blood Pressure:
Heart Rythm:
Breathing:
Return to [[hospital]] for a different test. Or go directly to another test:
[[ultrasound]]
[[chest x-ray]]
[[blood test]]
[[ECG or EKG]]
Or goto: [[Summary of all Steven's test results]].]Steven has a chest X-rays and the image of his heart looks normal.
Steven's image: <img src="v4c04a.jpeg" height="200">
Image of abnormal heart: <img src="" height="200">
(click:?results)[RESULTS: NORMAL HEART
Return to [[hospital]] for a different test. Or go directly to another test:
[[ECG or EKG]]
[[blood test]]
[[stress tests]]
[[ultrasound]]
Or goto: [[Summary of all Steven's test results]].]Heart ultrasound provides Steven's doctor with a moving images of his heart and an excellent picture to help the doctor evaluate his heart health.
The most common type of heart ultrasound is non-invasive and very easy on the patient. A specially trained technician, called a cardiac sonographer, uses a gel to slide a microphone-like device called a transducer over the chest area. This allows reflected sound waves to provide a live picture of your heart and valves. Heart Ultrasound uses the same technology that allows doctors to see an unborn baby inside a pregnant mother. No radiation is involved in heart ultrasound, and the technology can be used on people of all ages.
Steven may benefit from this type of test since he experienced unexplained chest pain (this type of test is also indicated for upper arm pain, a heart murmur, a heart attack, a heart defect, and/or a history of heart disease)
Steven's doctor can evaluate his heart health with this test.
See Steven's [test results.]<results|
(click:?results)[RESULTS: NORMAL HEART
Return to [[hospital]] for a different test. Or go directly to another test:
[[ECG or EKG]]
[[chest x-ray]]
[[blood test]]
[[stress tests]]
Or goto: [[Summary of all Steven's test results]].]<img src="12leadImage.gif" height="200">
An electrocardiogram records the electrical signals in your heart. It's a common test used to detect heart problems and monitor the heart's status in many situations. Electrocardiograms — also called ECGs or EKGs — are often done in a doctor's office, a clinic or a hospital room. And they've become standard equipment in operating rooms and ambulances.
An ECG is a noninvasive, painless test with quick results. During an ECG, sensors (electrodes) that can detect the electrical activity of your heart are attached to your chest and sometimes your limbs. These sensors are usually left on for just a few minutes.
This first test done to diagnose a heart attack records the electrical activity of your heart via electrodes attached to your skin. Impulses are recorded as waves displayed on a monitor or printed on paper. Because injured heart muscle doesn't conduct electrical impulses normally, the ECG may show that a heart attack has occurred or is in progress.
During this test, sound waves directed at your heart from a wandlike device (transducer) held on your chest bounce off your heart and are processed electronically to provide video images of your heart. An echocardiogram can help identify whether an area of your heart has been damaged by a heart attack and isn't pumping normally or at peak capacity.
Steven's doctor can evaluate his heart health with this test.
See Steven's [test results.]<results|
(click:?results)[RESULTS: NORMAL HEART
Return to [[hospital]] for a different test. Or go directly to another test:
[[chest x-ray]]
[[blood test]]
[[stress tests]]
[[ultrasound]]
Or goto: [[Summary of all Steven's test results]].]Double-click this passage to edit it.Double-click this passage to edit it.The clinic doctor does not seem worried and sends Steven home. He encourages him to get some rest, and stop stressing.
Steven goes home a bit dissapointed as he was hoping for something more from the doctor - but doctor knows best, [right?]<right|
(click: ?right)[That night he and his wife go out the their favorite mexican resturant, like they do many times a week. After a great meal and a couple margarita's they go home and to bed early. But he does not sleep well. So the next day Steven decides to taking the day off. After a couple cups of coffee he goes for a walk. He is feeling better already.
Lunch is a sandwich and a couple cups of coffee. Then to the beach with the family. Of course the kids want hotdogs, and Steven has only one. Feeling virtuous.
That night, however, Steven is feeling even worse than he did when he went to the clinic. His chest is really tight and his wife is now very concerened. She has been doing research on-line and everything she has read says: "Although the possibilities of things that cause chest pain are long, it’s very important that you don’t ignore chest pain. Chest pain is one of those symptoms that doctors take very seriously, and is rather challenging to dissect – therefore, it’s vital that you seek your doctor right away for a thorough history, exam, and possible [tests.]<tests|"]
(click: ?tests)[She encourages Steven to go directly to the [[hospital]], and skip the clinic and his regular doctor.]Since Steven all his test were thankfully normal the doctor digs deeper into what has been going on with Steven.
Digging a little deeper. Upon further questioning, Steven admitted that he’s been drinking 4-6 cups of coffee a day while putting in long hours at work, and eating spicy foods every day at a new local Mexican restaurant by his job and has been experiencing some heartburn after his meals.
Steven didn’t think anything of it since he didn’t sense [[acid reflux]], but he did admit that his chest pain occurs when he's lying down and improves upon sitting up at night.
Not all patients actually “sense” the acidic contents of the stomach refluxing up into the mouth. He also lives a rather sedentary lifestyle, is overweight, and consumes a good amount of foods that trigger acid reflux. After changing his diet significantly, having him sleep more upright at nights, and temporarily prescribing a medication that decreases the acidity of the stomach, his night time chest discomfort disappeared.
Double-click this passage to edit it."Chief complaint" is a medical term used to describe the “main symptom”.
For each “chief complaint,” doctors start to immediately compile a mental list of possible causes. For chest pain, this list is long and can include: In a short paragraph - or with bulleted points tell us what additional questions would you ask and why? Consider what you are trying to uncover.
You need to decide if you should send [[Steven home]] or to the [[hospital]] for tests.SUMMARY OF ALL STEVEN'S TEST RESULTS:
ECG or EKG : normal
Blood test : normal
Stress tests : normal
Chest x-ray : normal
Ultrasound : normal
Considering Steven's history and test results, write-up a one page summary of your diagnosis, or what you would do next. For example would you suggest additional tests (you need to make clear why they would make sense), or suggest additional questions you would want to ask him, to help you in your assessment.
passcode to diagnosis....Deciding what [[tests]] to run on a patient depends on many factors – their age, their personal medical history, their history of present illness, their family history, their vital signs in clinic (blood pressure, pulse, weight, oxygenation level, etc.), and the results of the physical exam.
So you can see that it takes a good deal of information gathering, before deciding on what tests to run.
Depending on the information available, doctors may run the following tests in a case like this which tests would you [run]<run|?
[[ECG or EKG ]]
[[blood test ]]
[[stress tests ]]
[[chest x-ray ]]
[[ultrasound ]]
In a short paragraph - or with bulleted points tell us what additional questions would you ask and why? Consider what you are trying to uncover.
you need to decide if you send [[Sarah home]] or to the [[hospital ]]<img src=12leadImage.gif height=”pixel #“>
An electrocardiogram records the electrical signals in your heart. It's a common test used to detect heart problems and monitor the heart's status in many situations. Electrocardiograms — also called ECGs or EKGs — are often done in a doctor's office, a clinic or a hospital room. And they've become standard equipment in operating rooms and ambulances.
An ECG is a noninvasive, painless test with quick results. During an ECG, sensors (electrodes) that can detect the electrical activity of your heart are attached to your chest and sometimes your limbs. These sensors are usually left on for just a few minutes.
This first test done to diagnose a heart attack records the electrical activity of your heart via electrodes attached to your skin. Impulses are recorded as waves displayed on a monitor or printed on paper. Because injured heart muscle doesn't conduct electrical impulses normally, the ECG may show that a heart attack has occurred or is in progress.
During this test, sound waves directed at your heart from a wandlike device (transducer) held on your chest bounce off your heart and are processed electronically to provide video images of your heart. An echocardiogram can help identify whether an area of your heart has been damaged by a heart attack and isn't pumping normally or at peak capacity.
Sarah's doctor can evaluate her heart health with this test.
See Sarah's [[ECG results.]]
Return to [[hospital ]] for a different test. Or go directly to another test:
[[chest x-ray ]]
[[blood test ]]
[[stress tests ]]
[[ultrasound ]]
Or goto: [[Summary of all Sarah's test results]].Blood tests. Certain heart enzymes slowly leak out into your blood if your heart has been damaged by a heart attack. Doctors will take samples of your blood to test for the presence of these enzymes.
For Sarah this means a quick draw of blood.
(click:?results)[RESULTS: XXXX
Return to [[hospital ]] for a different test. Or go directly to another test:
[[ultrasound ]]
[[chest x-ray ]]
[[ECG or EKG ]]
[[stress tests ]]
Or goto: [[Summary of all Sarah's test results]].]A stress test, also called an exercise stress test, gathers information about how your heart works during physical activity. Because exercise makes your heart pump harder and faster than usual, an exercise stress test can reveal problems within your heart that might not be noticeable otherwise.
An exercise stress test usually involves walking on a treadmill or riding a stationary bike while your heart rhythm, blood pressure and breathing are monitored.
Your doctor may recommend an exercise stress test if they suspect you have coronary artery disease or an irregular heart rhythm (arrhythmia). The test may also be used to guide your treatment if you've already been diagnosed with a heart condition.
(click:?results)[RESULTS: XXXXX
Return to [[hospital ]] for a different test. Or go directly to another test:
[[ultrasound ]]
[[chest x-ray ]]
[[blood test ]]
[[ECG or EKG ]]
Or goto: [[Summary of all Sarah's test results]].]Sarah's chest X-rays reveal signs of mitral valve disease - and the echocardiogram [ultrasound ] confirmed [[mitral stenosis.]]
<img src="Mitral stenosis annotated 01.jpeg" height="200">
Increased subcarinal angle to >90 degrees and loss of normal concavity below the left pulmonary artery due to left atrial appendage enlargement are signs of left atrial enlargement.
This leads to cardiomegaly. The left atrium enlarges and can sometimes cause a double right heart border as the edges of both the right and left atria are seem, although this is not so obvious in this particular case. If this sign is seen, a measurement can be taken from the edge of the left atrium to the left main bronchus, and a measurement greater than 7 cm is a sign of left atrial enlargement. The carina is splayed as result of the enlarged left atrium pushing up from underneath, and the left main bronchus assumes a more horizontal position. Finally, the left atrial appendage enlarges, seen as a loss of normal concavity just inferior to the left pulmonary artery. There may also be signs of cardiac failure although not clearly seen in this case. The commonest cause of this globally is rheumatic heart disease in which an endocarditis leads to valvular stenosis.
(click:?results)[RESULTS: enlargement of heart
Return to [[hospital ]] for a different test. Or go directly to another test:
[[ECG or EKG ]]
[[blood test ]]
[[stress tests ]]
[[ultrasound ]]
Or goto: [[Summary of all Sarah's test results]].]Heart ultrasound provides Steven's doctor with a moving images of his heart and an excellent picture to help the doctor evaluate his heart health.
The most common type of heart ultrasound is non-invasive and very easy on the patient. A specially trained technician, called a cardiac sonographer, uses a gel to slide a microphone-like device called a transducer over the chest area. This allows reflected sound waves to provide a live picture of your heart and valves. Heart Ultrasound uses the same technology that allows doctors to see an unborn baby inside a pregnant mother. No radiation is involved in heart ultrasound, and the technology can be used on people of all ages.
Steven may benefit from this type of test since he experienced unexplained chest pain (this type of test is also indicated for upper arm pain, a heart murmur, a heart attack, a heart defect, and/or a history of heart disease)
Steven's doctor can evaluate his heart health with this test.
See Steven's [test results.]<results|
(click:?results)[RESULTS: XXXXXX
Return to [[hospital ]] for a different test. Or go directly to another test:
[[ECG or EKG ]]
[[chest x-ray ]]
[[blood test ]]
[[stress tests ]]
Or goto: [[Summary of all Sarah's test results]].]SUMMARY OF ALL Sarah's TEST RESULTS:
ECG or EKG : reveals she is in the early phase of a heart attack
Blood test : normal
Stress tests : normal
Chest x-ray : normal
Ultrasound : normal
Considering Sarah's history and test results, write-up a one page summary of your diagnosis, or what you would do next. For example would you suggest additional tests (you need to make clear why they would make sense), or suggest additional questions you would want to ask him, to help you in your assessment.
passcode to diagnosis....Sarah's lower ECG reveals she is in the early phase of a heart attack and the clear elevation of the ST segments can be seen. For clarity the view of the leads V5 & V6 are expanded but the changes can be seen across many leads (II,III,AVF,V4-6) indicating an inferolateral myocardial infarction:- that is a heart attack affecting both the lower surface and lateral wall of the left ventricle. This patient would benefit from either thrombolytic drugs or primary angioplasty (PPCI)
<img src="Stemicomplete.jpg" height="200">
<img src="Figure-2-Recorded-evolution-of-ECG-waveform-showing-the-pathological-disturbances-after.png" height="200">
<img src="Figure-1-A-part-of-an-ECG-waveform-showing-the-cardiac-cycle-and-its-constituent.png" height="200">
Return to [[hospital ]] for a different test. Or go directly to another test:
[[chest x-ray ]]
[[blood test ]]
[[stress tests ]]
[[ultrasound ]]
Or goto: [[Summary of all Sarah's test results]].]In the classroom students can go through this individually or in groups. In either case I would have them pick one person to tarck in the game. At certain points they will be prompted to write up their ideas. At these points students can come together in a group to consider the options, or questions. Once they get to the end (where the full information regarding test results is revealed) students are asked to write up their diagnosis, or other thoughts. This is a good time for the whole class to come together and for each group to present the case they have followed the paths they took and the conclusions they have drawn - and why.
Once the class has discussed the cases, then the actual diagnoses can be revealed.Double-click this passage to edit it.