Jim's Palpitations
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How to use
Candidate:
- Read the brief below (1 minute).
- Take a history (6 minute).
- Answer viva questions (3 minute).
Patient/Examiner:
- Familiarise yourself with the history & examination findings
- After completing the history, viva the candidate
Candidate Brief
Please take a history from Jim, a 60yr old male who has been experiencing palpitations
Author: Joe Bloggs
Reviewer: Frank Haematuria
Date: 23/12/22
History
Examination
Viva
History
Presenting Complaint
- From time to time I can feel my heartbeat. If asked fast. If asked irregular.
- Timing: Lasts for a few minutes at a time, occurs daily.
- No triggers or pattern.
- Can walk 5miles on flat.
- Associated SOB
Systems Review
- CVS: No syncope, no chest pain, no ankle-swelling, no PND, no dizziness
- Mood: fine, palpitations are concerning, not as a result of feeling anxious, However quite worried that may not be able to care for wife if seriously ill.No depression, no longstanding anxiety, no previous panic attacks
- Thyroid: no weight change, no temperature
Red Flags
- No weight loss, no loss of consciousness, no tearing chest pain, no pain radiating into back or jaw
Previous Medical History
- Other medical conditions present: Diabetes, Hypertension, Gout
- Previous surgeries: Nil
- Medications: Metformin, Amlodipine, Allopurinol, nothing OTC
- Allergies: NKDA
Social History
- Smoking: Yes, if asked 15/day, if asked for 48 years (36 pack years)
- Alcohol: Yes, if asked 5 pints each week (10 units)
- Occupation: Part time cleaner, full time carer.
- Home: Wife with Freidrick’s ataxia, sole carer. Quite worried about this affecting ability to care for her.
Family History
- Dad had two strokes and IHD
- Mum had high blood pressure.
- If asked no sudden cardiac death in family.
ICE
- Ideas: Do I have a problem with my heart?
- Concerns: No-one else to look after wife. Very worried about the future if I’m seriously ill.
- Expectations: That you’ll order some tests.
Examination
- Inspection: Comfortable
- Pulse: Irregular
- Auscultation: Murmur over mitral area, louder in lateral position, mid-diastolic, rumbling
- Chest: Clear
- Ankles: No pitting oedema present
Viva
1. Summarise your relevant findings from your history and examination
- I spoke with Jim a full-time carer with a background of Diabetes and Hypertension, that has come in with intermittent irregular palpitations that I suspect is AF.
- He has sporadic SOB, a significant smoking history, and a FHx of cardiac disease. He has an irregular pulse and a diastolic mitral murmur.
- There is no chest pain, syncope, peripheral oedema, psychiatric history, or thyroid symptoms.
2. What are the most likely differentials?
- Atrial fibrillation – secondary to mitral stenosis
- Paroxysmal atrial fibrillation
- Anaemia
- Anxiety
- Hyperthyroidism
3. What investigations would you order for this patient based on these presentations?
Bedside
- ECG: no p waves, irregularly irregular rhythm, may show other arrythmia.
Bloods
- FBC: ?anaemia
- TFT: ?hyperthyroidism
- BNP: ?HF
- Cardiac Risk Factors: HbA1C: diabetes control, Lipids: atherosclerosis,
- U&Es/LFTs: Baseline before starting patient on medication
Imaging
- CXR: Cardiomegaly
- Refer to cardiology for echo.
- Echo: Mitral valve function, heart structure
4. Given a diagnosis of Atrial Fibrillation, how would you manage this patient?
Conservative
- Education, stroke awareness, CHADVASC & HASBLED, optimise diabetic and hypertensive control, diet, exercise, smoking cessation.
Medical:
- Pill in pocket with Flecainide if paroxysmal
- Rate control – beta blocker atenolol
- CCB diltiazem, Digoxin
- Rhythm control – cardioversion (Amiodarone, electrical)
- CHADVASC & HASBLED: Anticoagulation
Surgical
- Consider valve replacement