ACEM example: A 40 year old man presents with palpitations OSCE added anonymously 

 
You have 3 minutes reading time. This OSCE will run for a maximum of 7 minutes.

Scenario:

Mr. Peterson is a 40 year old previously well man who was admitted to emergency department by ambulance with palpitations. You should perform an initial assessment and manage the clinical situation.

View attached:  Attachment 1

Instructions for the candidate

Mr Peterson is a 40 year old man, previously well, who was riding his pushbike this morning as he often does, when he developed severe palpitaions and dizziness. He was noted by be pale and sweaty by by his friends so they called an ambulance.
Mr Peterson has just arrived. He is in resusitation room, and you have a registrar and a nurse with you. You should perform an initial assessment and manage the clinical situation dictates.

Domains being examined

  • Medical Expertise
  • Prioritisation And Decision Making
  • Communication
  • Leadership and Management
 
The candidate has 3 minutes reading time. This OSCE is expected to run for a maximum of 7 minutes.

For the actor

You are a fit active person with no previous medical history. You work for an insurance company but have regular recreational exercise. You are divorced and live alone.

You were out riding with your friends as you normally do two to three times per week, when you noticed severe palpitations. You could feel you heart beating rapidly and irregilarly. This has never happened before.

You felt dizzy when this happened so had to stop riding. Your friends noticed that you looked pale and unwell so called an ambulance. You did not lose consciousness.

The onset was about 30 minutes ago. You have been brought in by ambulance. The ambulance officers put up an IV line and gave you oxygen.

You had no chest pain or vomiting.
You are on no medication and you have no allergies.
You father had a heart attack aged 65 but is still alive.
You have not had heat intolerance, weight loss, tremor or sweating recently.
You see you GP most years for a check up but have had no problems.
You cholesterol is normal.

Now you are lying flat, you feel better but still feel your heart racing irregularly.

You are now concerned as you wonder if you have had a “heart attack”.

Nurse – You are an experienced ED nurse and should assist the candidate as you would do in a resusitation situation. When the candidate asks for monitoring you should apply it quickly and give immediate results.
SpO2 100% on O2, P 150, BP 80/60, decreased cap refill, GCS 15.
You can take bloods as requested but the results will not be available in the timeframe available. “sent off”.

You have immediate access to sedatives and analgesics as requested, including propofol, ketamine, fentanyl or midazolam.

For the examiner

Mr Peterson has presented with acute onset atrial fibrillation approximately 30 minutes ago. He was dizzy at the scene and noted to have a BP of 80 mmHg systolic. Ambulance officers have extablished IV access and given him a fluid bolus of 500 ml N saline. His BP has not improved. He has no chest pain but is aware of his heart racing irregularly.

ECG shows atrial fibrillation at 150/min with no ischaemic changes.

The candidate should manage the clinical situation. They should take a brief history and should proceed to sedation and DC cardioversion as Mr Peterson has AF with clinical instability with a clear recent time of onset. If the candidate does not proceed to cardioversion Mr Peterson’s BP will start to fall further.

Domains Assessment Objectives

Medical Expertise
Should recognize the need for urgent DC cardioversion.
Should proceed to do this in a clear efficient manner, after appropriate preparation should proceed with procedural sedation and cardioversion.

Prioritisation And Decision Making
Should correctly identify the need for cardioversion in an unstable patient with new onset AF

Communication
Should explain to the patient what has happened and the required treatment. Should get informed consent. Should explain to the nurse and doctor the current situation and the need for cardioversion.

Leadership and Management
Should manage the team giving them specific clear instructions and ensuring that the process of cardioversion is quick, safe and efficient.

Other Assessment Notes


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