Information Sheet for Candidates

Your work as RMO in a suburban hospital emergency

department and your next patient is a 40 year old
accountant, Mr. Ram, who presents to the emergency
department with palpitations which started about 30
mintues ago. There was no pain but some shortness of
breath and he got really scared and drove himself to the
hospital.
Yours tasks are to:
 Take a focused history
 Perform an examination
 Arrange appropriate investigations
 Explain your diagnosis and management to the patient
HOPC;
Mr.Ram was on his way to a client when he suddendly felt his heart racing like mad. This
caused some shortness of breath but no pain. It did not go away and he decided to drive
directly to the hospital. There were no other sypmtoms. He has had similar episodes
which never lasted that long when he used to smoke and drink a lot of coffee as a student,
but has not had any attacks for the last 20 years.
PHx.: except for appendicetomy at age 22 no other illnesses or operations., no
medications
FHx.: unremarkable
SHx.: married accountant, 3 children, no financial or family problems, stress at work
over the last 6 months, drinks a lot of coffee at work (10 cups per day), no allergies,
Examination: Not unwell looking 40 year old man, vital signs: BP 135?80, P 160,
irregular, RR 18, SaO2 98% on room air, Temp 37. BMI 23.No pathological findings.
Investigations:
1. ECG: see attached graph which shows an irregular heart rhythm without obvious
P waves. This is most likely the picture of atrial fibrillation (AF) with a rapid
ventricular response but could also be a narrow supraventricular tachycardia
(SVT).
2. FBE, U+E’s, cardiac enzymes, TFT
3. CXR
4. TOE (trans oesophageal echocardiograph)
DIAGNOSIS: Atrial Fibrillation!
AF is a common arrhythmia characterized by continuous and chaotic reentry of electrical
impulses within the atrial myocardium withhout effective atrial contractions, often with
decreased cardiac output and the formation of atrial thrombi.
The most common underlying causes are myocardial ischaemia, valvular disease,
hyperthyroidism, hypertension, hypokalaemia, hypomagnesaemia, anaemia, alcohol
abuse and use of stimulants like coffee.
Treatment:
Control of rate and rhythm and prophylaxis of thrombembolic complications!:
 RATE control: drugs which control AV nodal conduction like beta-blockers
(metoprolol), calcium channel blockers (verapamil, diltiazem) or digoxin.
 RHYTHM control: 1. medical cardioversion: sotolol, amiodarone, flecainide
2. elctrical DC cardioverision
3. radiofrequency ablation
 ATRIAL THROMBOSIS prophylaxis to prevent emboli (cerebral, mesemteric,
peripheral): anticoagulation with warfarin! This should be done in consultation
with a cardiologist.
Differential Diagnoses:
 SVT or Paroxysmal SVT:
Usually a regular rast rate of about 160 – 200 with uniform QRS complexes.
Managed with ADENOSINE (can be diagnostic for underlying AF or VT), vagal
manouvres (carotid sinus massage, head in cold water, Valsalva manouver –
breath-holding).
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Question
What is the rhythm in this 68 year-old female? * Difficulty rating
:

a) Multifocal atrial tachycardia

b) Wandering atrial pacemaker
c) Atrial fibrillation with rapid ventricular response
d) Atrial flutter with rapid ventricular response
e) Sinus arrhythmia with tremor artifact

This ECG shows atrial fibrillation with a rapid ventricular response rate at about 120 bpm
with borderline right axis deviation. Non-specific ST-T changes are present. There is
possible left ventricular hypertrophy and possible biventricular hypertrophy.

Multifocal atrial tachycardia and wandering atrial pacemaker are excluded as there is no
Answer:
evidence of discrete P waves, either normal or ectopic. Atrial flutter is excluded because
of the erratic response whereas in flutter there is a more regularized response.

This patient underwent successful DC cardioversion and was returned to sinus rhythm
the same day see (Case # 265.)

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