A-E Station 10

 

Station 10

What’s that feeling in my chest…

 

Candidate Instructions

Setting:

You are an FY1 doctor working on a medical ward. You have been called to see a patient admitted with pneumonia who has new onset tachycardia.


Name: Kevin Lane


Tasks:

1. Take a history of the presenting complaint only.

2. Complete an A-E assessment of the patient.

3. State your differential diagnoses to the examiner.

4. Please give your management plan to the examiner.

Simulated Patient Instructions

Briefing

Please act as the patient and reveal signs and results only as the candidate performs actions or requests tests.

Diagnosis: Atrial Fibrillation

You are Kevin Lane (DOB 19.06.1966, aged 55)

You started experiencing palpitations about 10 minutes ago. You have no other symptoms.

Appearance and Behaviour

You appear nervous.

Start the Timer and Begin

Examiner Instruction

 

As the candidate enters please give them this handover (acting as the nurse on the ward)

“Doctor, I’m glad you’re here, Mr Lane has been complaining of a funny feeling in his chest. His heart rate seems very fast.”

Intro

 

Airway

 

Assessment

Breathing

 

Assessment

Cardio

 

Assessment

Interventions/Investigations

Show the candidate the following ECG results only if they request them.

Disability

 

Assessment

Exposure

 

Assessment

Examiner Instruction

 

At this point please direct the candidate to give their differential diagnosis and any further management plans.

Diagnosis & Further Management

 

Diagnosis

Further Managemnet

Discussion

 

  • Whilst first line of rate control for Fast AF is typically a cardioselective beta-blocker such as bisoprolol or metoprolol, these have a pesky habit of dropping blood pressure.

  • Therefore in this case where the patient’s BP is already on the lower side, digoxin (or amiodarone in higher acuity areas such as CCU or ICU) would be a better agent.

  • Remember to always check local guidelines and confirm with a senior prior to doing this. As a general rule digoxin can be loaded to ~10-12 micrograms/kg (for a total loading dose of 0.75mg-1.5mg). In practice this is typically given as 0.25 mg IV intially followed by 0.25 Q6h for 2 further doses. It can also be loaded PO but has varying bioavavailability.

  • Digoxin would also be preferred for rate control in a patient with heart failure as it is positively inotropic (ie improves the hearts contractility) as opposed to beta-blockers which are negatively inotropic.

Submit for Scoring

Tags | A-E | AF | Atrial Fibrillation | Generally unwell patient

Station Written by: Dr Rishil Patel

Peer Reviewed by: Dr Benjamin Armstrong