A VIRTUAL CASE - INTRODUCTION
Dr Angelo Pieris Teaching Fellow in Clinical Pharmacology & Therapeutics.
July 2011
Updated by Dr Hew Torrance, July 2013
The people here are entirely made-up. Any resemblance to actual persons or fictional characters is purely co-incidental. No doctors were harmed in the making of this resource.
Select the best answer
A VIRTUAL CASE - PRESENTATION
Dr Partridge meets Mr Bull in The Royal Smallville Hospital's emergency room.
To play click on the "button" with the white triangle. Duration: 4 minutes.
To pause click again on the same button.
(The other button to the right starts the recording at the beginning!)
Imagine you are clerking Mr Bull.
What specific questions do you need to raise regarding:
1 His activities leading up to the presentation, 2 Symptoms, 3. Previous medical events?
Cover physical exertion, intake of all substances legal or illegal.
Define what was sensed/felt, don't just take his explanation at face value. i.e. one persons "bile" is anothers white sputum!
The SOCRATEs memnonic might be useful if pain or palpitations are mentioned:
Site, onset (time), character or nature of pain (not always answerable, be careful of leading the patient), radiation (Jaw, back, arms etc), alleviating factors (rest, posture, etc), timing (all the time/on-off, duration), exacerbating factors (activities, food, etc)
Previous events; collapse, syncope, pre-syncope, "funny-turns", blank spells, heart racing, sensation of irregular beats.
Chest pain.
Lifestyle habits, press for details and full disclosure. But be open about confidentiality rules and limits.
Family history (Collapse, heart defects, young deaths from cardiomyopathy or brugarda syndrome)
Medications. Allergies.
Examination
When the playback is finished record your ABC assessment of this patient from what you can gather. Mention what has been omitted.
He talks to the Dr so Airway is probably OK.
Breathing is not specifically addressed: Hopefully you picked up on this.
Circulatory collapse does not seem to be the case; BP is menttioned as "maintained". It is important for this to fall within normal limits and for this to be tolerated by the patient.
He is alert and seemingly orientated if possibly irritable. There is no disability mentioned.
Glucose has not been mentioned: It should be measured.
A VIRTUAL CASE - FLECAINIDE OR NOT FLECAINIDE
Mrs Partridge who has a MSc in Pharmacy is having a chat with Dr Partridge.
Listen to the pair discussing various treatment options. Try and pre-empt Mrs P's answers. Duration: 4 minutes
How might you have treated Mr Bull? Try and answer in regard to beta blockers and digoxin. (see other e-learning)
Fleicainide IS actually indicated by the European Society for Cardiology (As off June 2011) for our Mr Bull because it has a high success rate at converting new onset AF to sinus rhythm within a shorter period of time compared to many other anti-arrhythmics. (MR BULL DOES NOT HAVE ANY KNOWN UNDERLYING HEART DISEASE)
Digoxin; Not good for restoring sinus rythmn but good at rate control in inactive patients. Takes a while to act especially orally. Avoid if potassium is low. Good for people in heart failure or with a low blood pressure (Low BP - Think DC cardioversion/get help?)
Beta blockers; You are more likely to be familiar with the action of this drug than flecainide. This is shorter acting and there is flexibility to titrate the IV dose. There are fewer contra-indications than with flecainide e.g. broncho-spasm.
How might this "chat" not be acceptable behaviour in real life?
Anecdotes should not be recounted to a third party if there is a risk that the patient could be identified. Medical conditions may be discussed.
Judgement should not be expressed. However it could form the basis of reasoned advice to encourage the patient to adopt healthier behaviours.
And finally here are top tips on Flecainide.
A VIRTUAL CASE - ESSENTIAL MANAGEMENT OF ALL NEW A F
UNLESS CONTRA-INDICATED ALL PATIENTS PRESENTING TO HOSPITAL WITH NEW ONSET AF SHOULD BE STARTED ON ............. ON ADMISSION TO PREVENT THROMBO-EMBOLISM FORMATION IN THE HEART AND ENABLE ELECTRICAL CARDIOVERSION TO BE CARRIED OUT LATER IF DEEMED NECESSARY
If the patient is haemodynamically unstable the patient needs to be evaluated for electrical cardioversion immediately. So get help.
SIGNS OF HAEMODYNAMIC INSTABILITY CAN BE
A VIRTUAL CASE - LINKS
Finished?
Why not go off and go for a run
People participating in intensive high level aerobic sports have a higher incidence of atrial fibrillation compared to those who are healthy but less vigorous...So I should have a doughnut instead? No its a bell shaped curve Stupid! Doh!
Links:
Suggested reference resources:
Published by Queen Mary University of London. July 2011. Edited July 2013.
Author: Dr Angelo Pieris, BA, MBBS. Teaching Fellow, St Bartholemew's & The Royal London Hospitals.
Edited by Dr Hew Torrance MBBS, MSc, AKC. Academic Foundation Programme, Bart's Health NHS Trust.
Reviewed by Dr Mel Lobo PhD, FRCP, Consultant in Clinical Pharmacology St Bartholemew's & The Royal London Hospitals.