Station - Instructions for candidate
You are an intern in the Emergency Department of a regional hospital in Mandurah.
Margaret Doyle, a 79-year-old retired bookkeeper, has been brought in by her neighbour after two episodes this week of nearly fainting at the kitchen sink. She is lying on a monitored bed and feels well. The triage note and her ECG are printed on your sheet. The nurse can answer brief questions about her.
| Triage note | Two episodes of 'the room going grey' while standing, seconds long, no loss of consciousness, no injury; tired and short of breath on stairs for a month. HR 38, BP 108/64 mmHg, RR 16, SpO2 97% on room air, temperature 36.4 C, GCS 15. Medicines: metoprolol 50 mg twice daily (increased from 25 mg three weeks ago), perindopril 4 mg, atorvastatin 20 mg. No allergies. Lives alone; drives. |
|---|
Results provided:
12-lead ECG on arrival (with 10-second rhythm strip)
| Item | Value | Reference range |
|---|---|---|
| Rate | 38 /min | 60-100 /min |
| Rhythm | Regular P-QRS-T complexes, then a 3.2-second gap in which no P waves or QRS complexes appear, then the same P-QRS-T complexes resume | Regular sinus, no pauses over 3 seconds |
| Axis | Normal (+30 degrees) | -30 to +90 degrees |
| P waves and PR interval | Upright P before every QRS in II; PR 180 ms, constant | PR 120-200 ms |
| QRS duration and morphology | 90 ms; normal morphology | <120 ms |
| ST segments | Isoelectric | Isoelectric |
| T waves | Normal | Upright in lateral leads |
| QTc | 440 ms | <460 ms (female) |
Recorded on arrival; the patient felt light-headed during the gap.
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.