Station - Instructions for candidate
You are an intern in the Emergency Department of a Perth teaching hospital.
Marcus Reilly, a 28-year-old accounting student, walked into the department with a racing heart that started suddenly 40 minutes ago while he was studying. He is on a monitored bed with a nurse. The triage note and his ECG are printed on your sheet.
| Triage note | Sudden onset pounding heartbeat at rest 40 minutes ago; mild chest tightness and light-headed; walked in. HR 180 regular, BP 118/74 mmHg, RR 20, SpO2 98% on room air, temperature 36.8 C, alert. Past history: mild asthma (salbutamol as needed). No other medicines. No allergies. |
|---|
Results provided:
12-lead ECG on arrival
| Item | Value | Reference range |
|---|---|---|
| Rate | 180 /min | 60-100 /min |
| Rhythm | Regular; R-R intervals identical across the strip | Regular sinus |
| Axis | Normal (+50 degrees) | -30 to +90 degrees |
| P waves | No P wave identifiable before any QRS; a small positive deflection at the end of the QRS in V1 (pseudo-r') not present on old tracings | Upright P before each QRS in II |
| PR interval | Not measurable | 120-200 ms |
| QRS duration and morphology | 84 ms; normal morphology; no delta wave | <120 ms |
| ST segments | 1 mm horizontal depression in II, III, aVF and V4-V6 | Isoelectric |
| T waves | Upright, normal | Upright in lateral leads |
| QTc | Not reliably measurable at this rate | <450 ms (male) |
Recorded on arrival; the patient was symptomatic throughout.
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.