Student brief:

You are a medical student on placement in the emergency department and you have been asked to take a history from Morgan, a 65-year-old who has presented following a collapse.

• The student has been asked to take a history from a simulated patient
• Please kindly follow the script to simulate the consultation
• You will not be expected to undertake an examination
• Please answer in the negative to any specific questions about your condition where the answer is not outlined in the script

• About 4 hours ago you were walking to the shops (usual walk ≈ 1 km).
• You had been a little out of breath on the walk – this has become normal for you recently.
• You had some chest tightness earlier when walking, but recovered after standing still for a while.
• You don’t remember having any chest pain or palpitations just before the fall – but had intermittent pain earlier in the walk.

• You don’t remember collapsing.
• Wife was present and said: no body shaking, no incontinence, no drooling, did not hit your head; you are not aware of any injuries from falling.
• Unresponsive for approximately 30 seconds – wife said you were very pale.

• You were not confused afterwards and came round quite quickly.
• No injuries from the fall.
• You have felt okay since – just a little generally weak and “shaken up”.

• Progressively more short of breath over the last few months – you never used to get out of breath on this walk (done for years).
• Chest pain when walking sometimes – seems to be worsening.
• Never had a collapse like this before.

• Diagnosed with aortic stenosis about 5 years ago. Due for follow-up ≈ 1 year ago but unable to attend and it was never rescheduled. No interventions to date; cardiologist spoke about likely needing surgery but you haven’t heard anything since.
• High blood pressure
• High cholesterol

• Amlodipine 5 mg once daily
• Atorvastatin 20 mg once daily at night
• Aspirin 75 mg once daily
• No known drug allergies

• Father died from a heart attack aged 65
• Mother has high blood pressure, otherwise well
• No known family history of collapse, heart valve disease or sudden death

• Lives with wife in a 2-bed house; three grown-up daughters live nearby
• Retired (previously health and safety advisor)
• Ex-smoker: used to smoke 20/day for ≈ 40 years; now reduced to 5/day
• Drinks approx. 4 bottles of wine a week with wife – does not see any problem with this

• CVS: Shortness of breath on exertion, occasional chest tightness, no palpitations, no leg swelling
• Respiratory: No cough, wheeze or sputum
• GI: No nausea/vomiting, bowels and appetite normal
• Neuro: No headaches, visual changes, numbness or weakness

• Ideas: Thinks it could be related to the heart as the cardiologist warned about dizziness and fainting
• Concerns: Worried this might mean the heart is getting worse and that surgery may be needed; concerned about the missed cardiology follow-up
• Expectations: Want to know what caused the collapse and whether the heart is okay

Clinical Skills Foundation Course · Phase 1 Term 3 · CVS Role Plays

• What is concerning about this case? Likely cardiac syncope secondary to aortic stenosis
• What is aortic stenosis? (See standard resources e.g. Zero to Finals valvular heart disease)
• Expected examination finding: Ejection-systolic, high-pitched crescendo-decrescendo murmur radiating to the carotids