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

 

brugada-type-3

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)

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