Station - Instructions for candidate
You are an intern on placement in the Emergency Department of a Perth metropolitan hospital.
Rahul Singh, a 76-year-old of Indian-Australian heritage, presented at 2:30 am with central crushing chest pain that began at 1:15 am while he was sitting at home. The triage nurse has recorded his observations and handed you an ECG that was performed on arrival. You are asked to assess him.
| Triage observations at 2:30 am | Heart rate 94 bpm regular, blood pressure 162/96 mmHg, respiratory rate 18, oxygen saturation 98% on room air, temperature 37.0 degrees C, pain 8/10 |
|---|
Results provided:
ECG
| Item | Value | Reference range |
|---|---|---|
| Rate | 92 bpm | - |
| Rhythm | Regular sinus rhythm | - |
| Axis | Normal | - |
| P waves | Normal, one per QRS | - |
| PR interval | 180 ms | 120-200 ms |
| QRS duration | 90 ms | <120 ms |
| ST segments | Horizontal ST-segment depression 0.5 mm in V2-V4; T-wave inversion in lateral leads V5-V6, II, and aVL | - |
| T waves | Inverted in V5-V6, II, aVL indicating ischaemia | upright or biphasic |
| QTc | 420 ms | <440 ms |
ecg - read aloud by the examiner
Sinus rhythm at 92 bpm. Normal axis and QRS duration. ST-segment depression in the anterior precordial leads V2-V4 of 0.5 mm, and T-wave inversion in the lateral leads V5-V6, lead II, and aVL. These changes indicate acute subendocardial ischaemia affecting the left anterior descending and circumflex territories.
Look up an example image: LITFL NSTEMI ECG ischaemic changes
Your tasks are to:
- Take a focused history of the presenting complaint and relevant background, including risk factors and previous cardiac history.
- Perform a focused cardiovascular examination. Describe to the examiner what you would like to examine and the relevant findings will be provided to you.
- Interpret the ECG provided and explain your findings to the examiner.
- State your most likely diagnosis and up to three other important differentials to the examiner, giving brief reasons for each.
- Outline your immediate management plan, including medications, investigations, referral, and safety-netting.
- You do NOT need to summarise your findings to the examiner.
- Findings will be provided by the examiner on request during your examination.
- This is an emergency presentation; time is critical.
This is a 15-minute station, with 2 minutes of reading time.