Master Template (Stations)

Author – Joe Bloggs  Editor Dr Joe Bloggs

Last updated 00/00/00

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How to Use

Candidate:

  1. Read the brief below (1 minute). 
  2. Take a history (6 minute).
  3. Answer viva questions (3 minute).

Patient/Examiner:

  1. Familiarise yourself with the history & examination findings 
  2. After completing the history, viva the candidate

Candidate Brief

  • Please take a history from John, a 60yr old male who has been experiencing palpitations

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.
  • Inspection: Comfortable
  • Pulse: Irregular
  • Auscultation: Murmur over mitral area, louder in lateral position, mid-diastolic, rumbling
  • Chest: Clear
  • Ankles: No pitting oedema present

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
  1. National Institute for Health and Care Excellence. Breathlessness [Internet]. NICE; [revised 2022 Feb; cited 2023 Feb 16]. (CKS). Available from: https://cks.nice.org.uk/topics/breathlessness/

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