Instructions
You are a medical student on placement in the emergency department. Usha Mehta, 80, has been brought in by her daughter from her retirement village in Mandurah with five days of anorexia, nausea and vomiting. Her medicines, the triage handover, her ECG and her bloods are below.
Interpret the ECG and blood results provided
Outline to the examiner:
- Your most likely diagnosis
- Next steps in management
- You do not need to take a history or examine the patient
- You may ask the examiner about her current condition
Medicine list (from her pharmacy)
Digoxin 125 micrograms each morning Furosemide 40 mg each morning Perindopril 2.5 mg daily Apixaban 2.5 mg twice daily Clarithromycin 500 mg twice daily, started by her GP 7 days ago for a chest infection Paracetamol 1 g up to four times a day if needed Took this morning's tablets at 8 am
Triage handover
Atrial fibrillation and heart failure for 6 years; lives alone. Chest infection last week, settling. Off her food, vomiting 3 to 4 times a day for 5 days. Everything looks yellow-tinged for 2 days; her daughter finds her muddled. No diarrhoea, abdominal pain, chest pain or fever. No known allergies.
12-lead ECG for Usha Mehta, 80, at 2.10 pm
| Item | Value | Reference range |
|---|---|---|
| Rate | 44 /min (ventricular) | 60-100 /min |
| Rhythm | Irregularly irregular narrow complexes, with frequent early broad beats, all of one shape, about 1 beat in 6 | Regular sinus rhythm |
| Axis | +30 degrees | -30 to +90 degrees |
| P waves | None seen; fine, irregular baseline | Upright before every QRS |
| PR interval | Not measurable | 120-200 ms |
| QRS duration and morphology | Conducted beats 90 ms and narrow; early beats 150 ms and broad, all the same shape | Narrow, under 120 ms |
| ST segments | Downsloping, scooped depression of 1 to 2 mm in I, II, aVF and V4 to V6 | Isoelectric |
| T waves | Low and flat in V4 to V6; small U waves after the T waves in V2 and V3 | Upright in I, II and V3-V6 |
| QTc | 370 ms | <460 ms |
Blood tests for Usha Mehta, 80, taken at 2 pm
| Item | Value | Reference range |
|---|---|---|
| Sodium | 136 mmol/L | 135-145 mmol/L |
| Potassium | 3.1 mmol/L | 3.5-5.2 mmol/L |
| Bicarbonate | 33 mmol/L | 22-32 mmol/L |
| Urea | 17.8 mmol/L | 3.0-9.0 mmol/L |
| Creatinine | 162 umol/L (88 umol/L two months ago) | 45-90 umol/L |
| eGFR | 26 mL/min/1.73m2 | >90 mL/min/1.73m2 |
| Magnesium | 0.64 mmol/L | 0.70-1.10 mmol/L |
| Corrected calcium | 2.31 mmol/L | 2.10-2.60 mmol/L |
| Digoxin level (6 hours after the 8 am dose) | 3.6 nmol/L | 0.6-2.6 nmol/L |
| hs-Troponin T | 13 ng/L | <14 ng/L |
| White cell count | 8.6 x10^9/L | 4.0-11.0 x10^9/L |
| CRP | 16 mg/L | <5 mg/L |