I almost fainted.

You are the consultant in charge of the fast track area. You are asked to review a 21yo female who presents with pre-syncope. Please take a history from the patient and give advice about further investigations and management.
The patient’s ECG is attached.

Domains being examined

• Medical expertise
• Prioritisation and decision making
• Communication

 

Thank you to LITFL for this ECG! (link: http://cdn.lifeinthefastlane.com/wp-content/uploads/2009/12/Brugada-type-3.JPG)
Information for the actor (patient)

Hx

• 21yo female
• at work stacking shelves in woolworths when you began to feel light headed and felt you might faint
• possibly had palpitations but cannot be sure
• DID HAVE CHEST PAIN, felt mildly SOB,
• pre-syncope lasted for 45 seconds but still has ongoing mild chest pain and shortness of breath
• advised by employer to present to ED for assessment
• you do feel palpitations from time to time
• has fainted once before age 18 but this was when she used to have heavy periods
• recent long haul flight from USA where she went on a 2 week holiday
• on OCP
• mild left calf swelling/pain but thought this was because of a pre-existing netball injury

B/G:

• childhood asthma but no exacerbations since age
• nil else —> has never had an ECG
• meds: ‘nothing’ (only say OCP if specifically asked)
• NKDA
• non-smoker, social etoh
• Family Hx only give on specific questioning:
  • no family Hx of sudden cardiac death,
  • mother had a PE during pregnancy

Extra-instructions

• if the candidate has failed to reach a differential Dx by 5mins, ask ‘what do you think is wrong with me’ +/- ‘what will happen from here’

Medical expertise

•  differential diagnosis:
  • brugada as a possible diagnosis —> based on ECG and presyncope
  • PE based on HPI and ECG
• clear explanation about ECG changes and their implications, DDx:
  – could be brugada
  – could be PE
  – could be a congenital cardiac issue
  – could be nothing!
• asks about high risk features of brugada syndrome :

1. family members have same ECG
2. syncope
3. family Hx of SCD
4. irregular noctural respirations
5. VT on EP study

• 2 lines of Ix
  • PE: d-dimer, CTPA
  • if no PE —> need to assess for brugada
  • then discuss/justify in-patient vs outpatient assessment

Prioritisation and decision making

•  identification of potentially unwell patient who needs further Ix and likely admission

Communication

• simple explanations of pathologies and the ways in which are investigated

 

pre-syncope-osce (printable version)