Station - Instructions for candidate
You are an intern in the Emergency Department of a Perth metropolitan hospital.
Despina Papadopoulos, a 58-year-old warehouse worker of Greek-Australian heritage, presented 30 minutes ago with acute-onset palpitations and shortness of breath. She has never had this before. The triage nurse has recorded her observations and obtained a 12-lead ECG, which you have been asked to interpret. The patient is currently resting on the stretcher.
| Triage observations | HR 115 bpm, irregularly irregular; BP 128/76 mmHg; RR 18; SpO2 98% on room air; temperature 36.8 C; pain-free |
|---|---|
| Presenting complaint summary | Sudden onset of a racing heart and shortness of breath at rest this afternoon; no chest pain, no blackouts, no recent fever or illness |
Results provided:
12-lead ECG
| Item | Value | Reference range |
|---|---|---|
| Rate | 115 bpm | 60-100 bpm |
| Rhythm | Irregular with absence of P waves; fibrillatory baseline present | Regular sinus rhythm |
| Axis | Normal (approximately 45 degrees) | -30 to 90 degrees |
| P waves | Absent; replaced by fibrillatory waves | Present, upright in II, III, aVF; biphasic or inverted in aVR |
| PR interval | Not measurable | 120-200 ms |
| QRS duration | 80 ms | <120 ms |
| QRS morphology | Narrow complex; LBBB pattern present | Normal RBBB or normal axis |
| ST segments | Isoelectric; no ST elevation or depression | Isoelectric |
| T waves | Upright and symmetric in most leads | Upright and symmetric |
| QTc | Not reliably measurable | <450 ms males, <460 ms females |
ecg - read aloud by the examiner
A 12-lead ECG shows an irregularly irregular rhythm at approximately 115 bpm with no visible P waves. A fibrillatory baseline is present throughout. QRS complexes are narrow and of normal morphology. ST segments and T waves are normal.
Look up an example image: LITFL atrial fibrillation rapid ventricular response
Your tasks are to:
- Interpret the 12-lead ECG provided to you.
- State your most likely diagnosis.
- Provide two to three differential diagnoses with brief justification for why they are less likely.
- Outline your immediate management plan, including rate control and consideration of anticoagulation based on stroke risk.
- You do not need to take a history from the patient or perform a clinical examination.
- You will be asked one question by the examiner at the end of the station.
This is a 10-minute station, with 2 minutes of reading time.