Curriculum

IMT Interview Questions Bank

Overview of IMT Interview

0/1

Station 1: Ethical, Professionalism and Governance cases

0/34

Station 1: Suitability for IMT

0/12

Station 2: Clinical Scenario and Patient Handover cases

0/49

Text lesson

Case 1: Chest pain

Case summary

You are the IMT1 on call. A 45-year-old woman presents to the Emergency Department with chest pain and shortness of breath.

What are the key things you would want to ask in the history of this patient?

Given the brief vignette, a wide range of differential diagnoses is possible. Therefore, a focussed history should aim to identify:

Further details of the chest pain. For example, a structured approach could use SOCRATES:
- Site
- Onset
- Character e.g. sharp, dull, crushing, pleuritic
- Radiation
- Associated symptoms e.g. sweating, nausea, vomiting, palpitations
- Timing
- Exacerbating/relieving factors
- Severity
Onset and progression of shortness of breath
Red flag or associated symptoms
- Haemoptysis
- Recent immobility
- Tearing pain radiating to back
- Fever
Past medical history
- Cardiovascular disease and its risk factors (hypertension, diabetes, hyperlipidaemia)
- Respiratory disease e.g. asthma, COPD
- Malignancy
- Recent surgery
- Thromboembolic events
Drug history
Family history
- Cardiac disease
- Thromboembolic events
Social history
- Smoking history
- Recent travel or immobility

Interviewer prompt: Further clinical context is provided

From the history, the patient reports sudden onset shortness of breath and pleuritic chest pain for the past 6 hours. She feels lightheaded and has noticed some swelling in her left calf over the last week. She has no significant medical history but she recently returned from a long-haul flight from Australia two days ago. She is not on any regular medications.

What is your differential diagnosis?

Primary diagnosis: Acute pulmonary embolism (PE) in view of the sudden pleuritic chest pain and shortness of breath in the context of leg swelling and recent travel. Other differential diagnoses to consider include:

Acute coronary syndrome: Less likely given the lack of ischaemic ECG changes and presenting history.
Pneumothorax: Unlikely as chest X-ray is clear.
Pneumonia: Unlikely with no fever, normal WBC and clear chest X-ray.
Aortic dissection: Consider if there is tearing chest pain radiating to the back.

What next steps would you take?

I would initially assess the patient in an A-E manner. To refine my differential diagnosis, I would perform bedside investigations, including observations and ECG, and arrange blood tests and imaging, initially a chest X-ray and followed by a CT pulmonary angiogram (CTPA) scan.

Immediate actions:

A-E assessment.
Arrange blood tests, including
- FBC and CRP: check for inflammation
- U&E: check renal function before starting anticoagulation
Arrange an ECG.
Request a chest X-ray.
Arrange a pregnancy test.
In case of haemodynamic instability, prepare for thrombolysis.

Further actions:

If the chest X-ray is negative, I would proceed with requesting a CT pulmonary angiogram (CTPA) given the high suspicion of pulmonary embolism. If CTPA is contraindicated (e.g. allergy to contrast or renal impairment), consider a ventilation-perfusion (V/Q) scan.
While awaiting the CT scan, start treatment with anticoagulation. This can be a direct oral anticoagulant (DOAC) or treatment-dose low molecular weight heparin (LMWH), depending on local guidelines.
Consider sending a troponin blood test to check for myocardial infarction, although this is commonly mildly raised in pulmonary embolism

Interviewer prompt: Obs and investigation results provided

Observations

Heart rate	124 bpm
Blood pressure	1108/65 mmHg
Respiratory rate	24/min
Oxygen saturations	90% on room air
Temperature	36.9°C

Initial Investigations

Investigation	Result	Normal Range
WCC	8 ×10⁹/L	4–11 ×10⁹/L
CRP	2 mg/L	<5 mg/L
Sodium (Na⁺)	142 mmol/L	135–145 mmol/L
Potassium (K⁺)	4.2 mmol/L	3.5–5.0 mmol/L
Urea	5.0 mmol/L	2.5–7.8 mmol/L
Creatinine	75 µmol/L	60–110 µmol/L

ECG

Source: Ewingdo, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons

Chest X-ray

What is your interpretation of these results?

The patient is hypoxic, so would require hospital admission. Their current blood pressure indicates they are haemodynamically stable although they are mildly tachycardic. The blood tests presented are within normal range. No inflammatory changes are present and renal function is normal, permitting the use of oral anticoagulation. The ECG is consistent with sinus tachycardia with no ischaemic changes present. The chest X-ray shows clear lung fields with no abnormality present. These results have strengthened PE as the primary diagnosis. Therefore, I would proceed with arranging a CTPA or V/Q scan to confirm the diagnosis. In terms of the other differential diagnoses:

Acute coronary syndrome: Less likely given the lack of ischaemic ECG changes and presenting history.
Pneumothorax: Unlikely as chest X-ray is clear.
Pneumonia: Unlikely with no fever, normal WCC and clear chest X-ray.
Aortic dissection: No history of tearing chest pain

How would a D-dimer test influence your decision-making in pulmonary embolism?

D-dimer tests are sensitive but not specific tests of thrombosis. Their value depends on the pre-test probability. In cases of low probability of PE, a negative result can be useful to rule out the disease. However, they are less helpful in cases where there is an intermediate or high suspicion of PE/DVT as it cannot safely rule out PE. In such cases, imaging to check for PE should still be performed.

What potential treatments would you offer?

Supportive measures:

Oxygen therapy to correct hypoxia as current SpO2 is 90%; aim to maintain SpO2 ≥94%.
IV fluids cautiously if there is evidence of hemodynamic instability.

Anticoagulation:

LMWH or direct oral anticoagulants (DOACs) such as apixaban or rivaroxaban. In view of the patient requiring inpatient admission, it may be more appropriate to use LMWH. Transition to oral anticoagulation based on long-term plan.

Thrombolysis:

For massive PE with hemodynamic compromise, consider alteplase 10 mg IV bolus followed by 90 mg infusion over 2 hours.

Surgical or interventional options:

Consider embolectomy or catheter-directed thrombolysis in severe cases if thrombolysis is contraindicated.

How would you go about communicating with any people (e.g. patients, family members, colleagues)?

Patient and family

Explain the likely diagnosis and the need for anticoagulation.
Reassure them that treatment can be life-saving but explain the potential risks (e.g. bleeding with thrombolysis if needed).
Emphasise the importance of follow-up to assess the need for prolonged anticoagulation.

Colleagues

Escalate to the haematology or respiratory team if there are complexities such as high bleeding risk or if thrombolysis is being considered.
Ensure the nursing team is aware of monitoring requirements (e.g. oxygen saturation, anticoagulation).

What scoring systems may be useful in this case?

In the case of a suspected pulmonary embolism (PE), several scoring systems can guide clinical decision-making and risk stratification. The two-level Wells score can be used to estimate the probability of PE. A PE is unlikely in cases with a score of 4 or less.

Clinical feature	Points
Clinical features of deep vein thrombosis (DVT; minimum of leg swelling and pain with palpation of the deep veins)	3
An alternative diagnosis is less likely than PE	3
Heart rate greater than 100 beats per minute	1.5
Immobilisation for more than 3 days or surgery in the previous 4 weeks	1.5
Previous DVT or PE	1.5
Haemoptysis	1
Cancer (receiving treatment, treated in the last 6 months or palliative)	1

Another scoring system that may be useful is the HAS-BLED score to estimate bleeding risk on anticoagulation.

Handover

Situation

Hi, my name is X, I’m one of the IMT1 doctors. This is a 45-year-old woman presenting with acute onset shortness of breath and pleuritic chest pain. She recently returned from a long-haul flight and is hypoxic with oxygen saturations of 90% on room air.

Background

She has no significant past medical history but reports left leg swelling for one week. Initial investigations showed normal inflammatory markers and kidney function.

Assessment

She is highly likely to have a pulmonary embolism. We are arranging a CTPA but her haemodynamics are borderline with a blood pressure of 108/65 mmHg. She has received oxygen and treatment-dose LMWH. There is no evidence of contraindications to anticoagulation.

Recommendation

I recommend close monitoring of her haemodynamics. If there is deterioration, she may require thrombolysis or ICU-level care. Please arrange for an urgent review by the respiratory team if thrombolysis is indicated.