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 :
- family members have same ECG
- syncope
- family Hx of SCD
- irregular noctural respirations
- 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)