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Оценочный лист (check-list)
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Station 2
Clinical case: "The relief of pain in acute coronary syndrome"
Situational task: You are a paramedic. You arrived on a call to a man of 57 years with intense pain behind the breastbone.
Task:
Ø Collect medical history and perform examination of the patient
Ø Guide the interpretation of the ECG
Ø Determine the presence of markers of myocardial necrosis
Ø Formulate a preliminary diagnosis
Ø Provide emergency care
Ø Determine patient management
Equipment: volunteer, tonometer, stethoscope, ECG strips, medicines: Nitroglycerin tablet 0.5 mg, or spray, Aspirin, Clopidogrel tablet 75 mg – 4 - piece, oxygen, Morphine 1%- 1,0, Heparin, Isosorbide dinitrate (Isoket) 0,1% - 10,0 ml, Sodium Chloride 0,9% - 10,0 - 2 pieces, Sodium Chloride 0,9% - 100,0 - 2 pieces, syringes, 10,0 - 5, the system for intravenous infusion.
The text of the scenario for the standardized actor (patient) and description its role:
Complains: severe pain in the chest, shortness of breath, feeling of fear, cold clammy sweat, dizziness.
| The formulization of the question for the actor | Answer |
| What type of pain? Where the pain is localized? Could you show with hand? | Pressing (presses fist to the sternum), burning |
| How long does the pain last? | More than 6 hours |
| What is the cause of the pain? What do you think? | The pain appeared after emotional stress |
| Do they give any place of pain? | Yes, in the left hand and subscapular region |
| What else is bothering, except the pain? | Palpitations, shortness of breath, weakness, sweating, a sense of fear. |
| Something was taken in order to have the pain gone? | Have taken Nitroglycerin tablets under the tongue twice, but the pain had not gone. Last time has been 5 min ago. |
In the anamnesis: suffering with IHD for 2 years, consists of "D" account. Periodically takes Kardiket, Cardiomagnyl. Had received inpatient treatment in the CCC. Two months ago suffered a stroke. The maximum increase in blood pressure up to 160/100 mm rt. st. Regularly takes antihypertensive medications. Mum suffered coronary artery disease and died at age 52 from a heart attack. Does not smoke.
This deterioration of more than 6 hours, when appeared the above complaints, called the ambulance.
Objectively: pale skin covered with cold clammy sweat. No peripheral edema. In the lungs vesicular breathing, wheezing no. The RR of 20 per minute. Muffled heart sounds, regular rhythm. BP is 140/ 90 mm Hg. Heart rate of 92 per min.
Check-list
| № | Evaluation criteria | Complete answer | Incomplete answer | Incorrect answer |
| Come to the patient, greet the patient, introduced him/herself, established initial contact with the patient. | 1,0 | 0,5 | ||
| Specified complaints and anamnesis data defining the diagnosis: • Intense pressing pressure behind the sternum with irradiation in the left shoulder and in left neck, long lasting, not suppressed by nitrates, have arisen after stress • Shortness of breath at the slightest movement • Feeling of fear, cold sticky perspiration • Palpitation, dizziness During the collection of anamnesis simultaneously counted the pulse and told the patient that he had a frequent pulse | 1,0 | 0,5 | ||
| Conducted a physical examination of the patient: Measured blood pressure, performed auscultation of the lungs and heart | 1,0 | 0,5 | ||
| Put preliminary diagnosis of patient: acute coronary syndrome, calmed patient down and told about the need to ECG | 1,0 | 0,5 | ||
| Prescribed the Nitroglycerin sublingual tablet 0.0005 g or Nitroglycerin spray 0.4 mg/dose under the control of blood pressure | 1,0 | 0,5 | ||
| Provided fresh air and oxygen inhalation | 1,0 | 0,5 | ||
| Gave acetylsalicylic acid in a dose of 150-300 mg chew and drink water. | 1,0 | 0,5 | ||
| Took from the table results of an electrocardiogram, interpreted, explained patient that ST-segment elevation in the chest leads confirms a preliminary diagnosis of acute coronary syndrome | 1,0 | 0,5 | ||
| Gave Clopidogrel 300 mg (4 tablets) orally. | 1,0 | 0,5 | ||
| Established a venous access to an ulnar vein on a phantom connected a ready dropper with a physiological solution | 1,0 | 0,5 | ||
| Explained to the patient that he/she will do anesthetic preparation. Examiner found out allergic anamnesis. Carried out anesthesia with Morphine 1% -1,0 on a solution of sodium chloride 0,9% to 20,0 intravenously fractional by 3 mg solution (in a rubber adapter to the dropper needle). During the introduction of Morphine periodically asked about the nature of the pain syndrome, stopped the injection after the disappearance of pain. | 1,0 | 0,5 | ||
| Identified troponin T via express test – result is negative | 1,0 | 0,5 | ||
| Taking into account the rapid pulse, administered Metoprolol 0.1% -5.0 intravenously fractional (in the rubber adapter to the dropper needle) | 1,0 | 0,5 | ||
| Defined further tactics: - Hospitalization in the nearest cardiology department or hospital; If transporting takes more than 30 minutes, fibrinolytic therapy is indicated. Specified the presence of contraindications to thrombolysis, asking the patient for a history of ADCC, trauma, surgery, peptic ulcer, anticoagulant therapy, hemorrhagic syndrome | 1,0 | 0,5 | ||
| Found out that the patient suffered by acute disorders of cerebral circulation 2 months ago, examiner explained to the patient that carrying out thrombolytic therapy is absolutely counter-indicative for him. Examiner determined the tactics of management if thrombolysis is contraindicated. | 1,0 | 0,5 | ||
| Introduced Heparin 5000 U intravenously jet, or Fondaparinux 2.5 mg s/c, or Enoxaparin i/v bolus 30 mg; | 1,0 | 0,5 | ||
| Measured blood pressure. With blood pressure not lower than 90 mm hg connected system for intravenous injection of Isosorbide Dinitrate (Isoket) 0,1% -10,0 ml, previously diluted with sodium chloride solution 0,9% - 100,0 with the initial speed of 3-4 drops per minute. | 1,0 | 0,5 | ||
| Carried out a control study of blood pressure, heart rate and rhythm of the heart, noted improvement in the condition - relief of pain, stable blood pressure, a decrease in heart rate to 76 per 1 minute | 1,0 | 0,5 | ||
| Defined further treatment tactics: - Emergency hospitalization in a medical institution, in which there are conditions for performing coronary angiography and PCI. Transport in the position of lying with a raised head end under the control of blood pressure, heart rate and rhythm. Through the dispatcher Examiner informed the reception staff of the walkie-talkie or the telephone about the delivery of the patient | 1,0 | 0,5 | ||
| Effectiveness of communication: Competently informed the patient, showed self-control, confidently carried out the skills | 1,0 | 0,5 |
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Total maximum score for the station – __100____.
The time allotted for the job – __7__ minutes.
Reviewed and approved at the meeting of the Department of emergency medical care
protocol No.____2_ " __28___"_09____2015
Head. chair, MD Professor of Turlanov K. M.
Reviewed and approved at the meeting of the COP of the educational Department of internal diseases, protocol No._____ from " __ "_10____2015.
Chairman of CEP M. D. Professor Kurmanova G. M.
Оценочный лист (check-list)
по клиническому случаю «Купирование болевого синдрома при ОКС»
| № | Критерии оценки | Полный ответ | Неполный ответ | Неправильный ответ |
| Подошел к пациенту, поздоровался, представился, установил зрительный контакт. | ||||
| Уточнил основные жалобы и данные анамнеза, Одновременно провел подсчет пульса при сборе анамнеза и сказал пациенту, что у него частый пульс Уточнил характер боли, локализацию, продолжительность, иррадиацию | ||||
| Измерил АД, ЧСС, провел аускультацию сердца и на основании жалоб, анамнеза, объективных данных установил предварительный диагноз: острый коронарный синдром проинформировал больного о необходимости снятия ЭКГ | ||||
| Взял со стола результаты ЭКГ, интерпретировал, объясняя пациенту, что подъем сегмента ST в грудных отведениях подтверждает предварительный диагноз: острый коронарный синдром, успокоил его Определил тропонин Т с помощью экспресс-теста - результат отрицательный | ||||
| Дал нитроглицерин сублингвально – таблетка 0,0005 г или аэрозоль нитроглицерина 0,4 мг/доза под контролем АД Дал ацетилсалициловую кислоту в дозе 100-300 мг разжевать, запить водой. Дал клопидогрель 300 мг (4 табл) внутрь | ||||
| Назначил и провел ингаляцию кислорода Наладил венозный доступ к локтевой вене на фантоме подключил готовую капельницу с физиологическим раствором | ||||
| Объяснил больному, что сделает обезболивающий препарат Предварительно выяснил аллергоанамнез Провел обезболивание морфином 1%-1,0 на растворе натрия хлорида 0,9% до 20,0 вв дробно по 3 мг раствора (в резиновый переходник к игле капельницы). Во время введения морфина периодически спрашивал о характере болевого синдрома, прекратил введение препарата после исчезновения болей. Ввел гепарин 5000 МЕ внутривенно медленно | ||||
| Измерил АД. При АД не ниже 90 мм рт. ст. подключил в систему для вв введения изосорбида динитрат (изокет) 0,1%-10,0 мл предварительно разведенный раствором натрия хлорида 0,9%- 100,0 с начальной скоростью 3-4 капли в мин. Учитывая учащенный пульс ввел метопролол 0,1%-5,0 вв болюсно (в резиновый переходник к игле капельницы) | ||||
| Провел контрольное исследование АД, ЧСС и ритма сердечной деятельности, констатировал улучшение состояния – купирование боли, стабильное АД, уменьшение ЧСС до 76 в 1 мин. Учитывая что, у больного в анамнезе недавно перенесенный ОНМК, тромболитическую терапию не проводил Госпитализация больного в реанимационное отделение профильного стационара. Транспортировать на носилках в положении лёжа с приподнятым головным концом под контролем АД, ЧСС и ритма | ||||
| Компетентно информировал пациента, проявил самообладание, уверенно выполнял навыки |
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Итого максимальный балл по станции – __100____.
Время, отведенное на задание – __7__ минут.
Рассмотрено и одобрено на заседании кафедры скорой и неотложной медицинской помощи,
протокол № 2_ от «__28___»_09____2016г
Зав. кафедрой д.м.н. проф. Турланов К.М.
Рассмотрено и одобрено на заседании КОП факультета общей медицины,
протокол №___4__ от «10__»_01____2017 г
Председатель КОП к.м.н. доц. Карибаева Д.О.
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