Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a doctor working in an emergency department. Your next patient is called Carol Smith, a 46-year-old female who presented with a "funny" spell. Please take a history and perform a relevant examination.
Patient History:
Your name is Carol Smith. You are a 46-year-old lady who had a funny spell. When you have been asked specifically what this means, you had a feeling of dizziness and light-headedness 3 hours ago. You did not feel the room was spinning.
On further questioning, you feel that your heart was racing at the time, and you are very worried about this. You weren’t doing anything particular at the time. You were sitting on a chair watching the television.
You generally have breathlessness for many years, and it is only mild – nothing significant/ worsening in the past few days. You do feel a bit tired all the time. Your legs are always swollen.
No loss of consciousness. No chest pain. No peripheral swelling. No wheeze. No cough. No seizure activities. No fever or recent infection.
Ideas, Concerns, Expectations:
You are not sure whether this is a panic attack, as generally, you are an anxious person. You are very concerned that this might be related to the heart. Your father died of a heart attack when he was around 40. You do not want to die. You want to see if there are any medications you can take.
Past Medical History:
Received thyroidectomy, high blood pressure, diabetes type 2, a valvular problem - but you do not remember exactly what it is.
Drug History:
Thyroxine, ramipril, metformin, statin
NKDA
Family History:
Heart attack from father at the age of 40, rheumatoid arthritis from mother
Social History:
Ex-smoker (used to smoke 15 cigarettes a day for 20 years)
Drink around 4 pints of lager per week
Work as a freelance writer
Living with your dog
Examination Findings:
Irregularly irregular pulse, tachycardia, signs of heart failure i.e. pitting oedema, bibasal crackles on auscultation. An ejection systolic murmur can be heard in the aortic region on auscultation.
Differentials:
Arrhythmias e.g. Atrial Fibrillation…etc.
Aortic Stenosis
Underlying heart failure
Anxiety/panic attack
Rule out other cardiorespiratory causes: ACS...etc.
Investigations:
Bedside:
Observations: including lying and standing BP
ECG / Telemetry
Bloods:
TFTs (may be driven from levothyroxine), FBC (anaemia > heart failure, infection), U&Es (electrolyte imbalance > arrhythmias, consideration for digoxin to control HR), coagulation screen, glucose/ lipid profile/ hba1c (cardiovascular risk factors), CRP (inflammatory markers), NT-proBNP (heart failure), consider serial troponin if suspecting silent MI which can trigger arrhythmias
Imaging:
CXR (structural cardiac problems, pulmonary oedema, infection)
Echo (TTE/TOE) – structural/ functional heart diseases
Consider CT/ MRI Head if suspicion of stroke/cerebral causes
Other considerations, if appropriate: CT coronary angiography / stress testing for ACS/ cardiac problem
Management:
Conservative:
Lifestyle e.g. avoiding triggers ie alcohol + caffeine / weight loss/ physical activity
Review medications e.g. medications that can prolong QTs, levothyroxine, those that can cause electrolyte imbalance…etc
Cardiology specialist review / follow up
Consider hospital admission if severe AF e.g. HR > 150bpm, sBP< 90, ongoing severe symptoms or signs of stroke/TIA/HF
Medical:
All patients with AF should have rate control unless:
Reversible cause for AF
New onset of AF in 48 hours
AF causing Heart Failure
Symptomatic despite rate controlled.
Rate Control:
Betablocker i.e. atenolol
Calcium Channel Blocker i.e. Diltiazem
Digoxin (Patients with sedentary lifestyle)
Rhythm Control:
Flecainide
Amiodarone (for structural heart disease)
Long-term treatment:
Long-term AF control: betablocker/ dronedarone/ amiodarone
For paroxysmal AF: Consider pill in the pocket strategy i.e. flecainide/ amiodarone.
Consider anticoagulation long-term - CHADSVASc vs HAS-BLED score e.g. DOACs such as apixaban/ warfarin
Cardioversion:
Electrical cardioversion is used for life-threatening AF + haemodynamic instability.
Delayed Cardioversion (Stable + > 48 hours from onset): Anticoagulation for at least 3 weeks before cardioversion (due to possible clot in atria that can cause a stroke).
Surgical:
If severe + drug treatment is unsuccessful, consider left atrial ablation/pacing and atrioventricular node ablation.
Viva Questions:
What would you see in an ECG for Atrial Fibrillation?
What is CHADsVASc Score vs HAS-BLED score?
How does AF cause stroke?
What are the benefits of using DOACs vs Warfarin?
How do we reverse the action of warfarin?
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