Station - Instructions for candidate
You are an intern in the Emergency Department of a Perth metropolitan hospital.
Andreas Nikolaidis, a 76-year-old man, collapsed while gardening this morning. He is now alert. The ambulance handover notes and observations are provided.
| Ambulance handover | Attended garden collapse this morning. Patient was witnessed to collapse by his wife. Now alert and oriented. No seizure activity witnessed. On antihypertensive medication. No prior cardiac history reported. |
|---|---|
| Observations on ED arrival | HR 48 regular, BP 138/84 mmHg, RR 16, SpO2 99% on room air, temperature 36.8 C, pain score 0/10. Patient alert, mild confusion resolving, no focal neurological signs. |
Results provided:
12-lead ECG
| Item | Value | Reference range |
|---|---|---|
| Rate | 40 bpm | 60-100 bpm |
| Rhythm | Regular at 40 bpm; P waves at 90 bpm independent of QRS | Normal sinus rhythm |
| PR interval | No fixed relationship between P and QRS | 120-200 ms |
| QRS duration | 80 ms | 80-120 ms |
| Axis | Normal (-30 to +90 degrees) | -30 to +90 degrees |
| ST segments | Isoelectric | Isoelectric |
| T waves | Normal | Normal |
ecg - read aloud by the examiner
A 12-lead ECG shows slow regular QRS complexes at 40 per minute. P waves are visible at a faster rate of approximately 90 per minute and do not coincide with the QRS complexes - the atrial and ventricular rhythms are independent. The QRS complexes are narrow. ST segments and T waves are normal. There is dissociation between the P waves and QRS complexes.
Look up an example image: LITFL atrioventricular dissociation bradycardia
Your tasks are to:
- Take a focused history of the collapse and relevant background.
- Perform a focused cardiovascular examination, including assessment of blood pressure lying and standing (postural blood pressure).
- Interpret the provided ECG and explain to the examiner what you see and what you think it means.
- State your most likely diagnosis and at least two other diagnoses you would need to exclude.
- Outline your initial management plan, including specific drugs (if appropriate, with dose and route) and who needs to be involved.
- You do NOT need to summarise your findings to the examiner.
- Findings will be provided by the examiner on request during the examination.
This is a 15-minute station, with 2 minutes of reading time.