Station - Instructions for candidate
You are an intern in the Emergency Department of a Perth teaching hospital.
Graham Pearce, a 66-year-old retired electrician, has been brought in by ambulance with palpitations and light-headedness that started 30 minutes ago while he was carrying shopping. He is on a monitored bed with a nurse. The ambulance handover and his ECG are printed on your sheet.
| Ambulance handover | Sudden palpitations and light-headedness 30 minutes ago with some chest discomfort; pale and sweaty on arrival. HR 170 regular, BP 98/60 mmHg, RR 22, SpO2 96% on room air, GCS 15, temperature 36.5 C. Past history: heart attack three years ago with a stent; 'weak heart' on his last scan. Medicines: metoprolol (ran out four days ago), aspirin, atorvastatin, ramipril. No allergies. |
|---|
Results provided:
12-lead ECG on arrival
| Item | Value | Reference range |
|---|---|---|
| Rate | 170 /min | 60-100 /min |
| Rhythm | Regular; occasional P waves visible in lead II that bear no fixed relation to the QRS; one beat of intermediate morphology in the strip | Regular sinus |
| Axis | -110 degrees (extreme) | -30 to +90 degrees |
| P waves and PR interval | No consistent P wave before the QRS; PR not measurable | Upright P before each QRS in II |
| QRS duration and morphology | 160 ms; uniform from beat to beat; predominantly positive in V1 through V6; no RSR' pattern; onset to nadir of S in V6 more than 100 ms | <120 ms |
| ST segments | Discordant to the QRS in all leads | Isoelectric |
| T waves | Discordant to the QRS; broad | Upright in lateral leads |
| QTc | Not measurable at this rate | <450 ms (male) |
Recorded on arrival. An old ECG from his discharge three years ago is available from the examiner.
Your tasks are to:
- Interpret the ECG provided.
- State your most likely diagnosis and differential diagnoses to the examiner.
- Outline your immediate management plan to the examiner.
- The examiner will ask you two questions at the end.
- You do NOT need to take a history or examine the patient; the nurse can answer brief questions and will carry out your instructions.
- The patient is on a cardiac monitor; further results are available from the examiner on request.
This is a 10-minute station, with 2 minutes of reading time.