Physician's Assistant

Refined clerking Mon 29 September 2025 00:19

Last Modified: 27 weeks ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Syncope

History of Presenting Complaint:
Admitted in late 2024 with atrial fibrillation and fast ventricular response. Initially managed with rate control strategy using beta blockade and digoxin. Echo revealed ejection fraction 21% with mild mitral regurgitation, prompting switch to rhythm control strategy. Started on amiodarone during admission and digoxin stopped at that time.

Underwent elective DC cardioversion in July 2025. Post-cardioversion echo demonstrated impaired left ventricular systolic function with LV dyssynchrony, dilated left ventricular internal dimensions, normal wall thickness, biatrial enlargement, and mild mitral, tricuspid and pulmonary regurgitation. Ejection fraction improved to 39%.

Today, felt palpitations and was concerned about atrial fibrillation recurrence. Took digoxin 125 micrograms at home, previously told to stop, (old prescription from GP records) despite having already taken amiodarone and bisoprolol that day. Around lunchtime experienced syncopal episode, followed by presyncope. No chest pain, shortness of breath or fevers. Has had productive cough with white sputum over recent days but feels otherwise well.

On ambulance arrival, heart rate 20 with complete heart block. In ED, heart rate remained 20 with fusion beats and short runs of ventricular tachycardia on ECG. Atropine attempted with no response. Blood pressure unrecordable but patient remained alert. Started on isoprenaline infusion which improved heart rate to 30-40s. Arterial line inserted for invasive blood pressure monitoring.

B-B reversal undertaken with glucagon also.

Past Medical History:
• Atrial fibrillation
• Osteoarthritis
• Osteoporosis
• Total abdominal hysterectomy and bilateral salpingo-oophorectomy (December 2002)

Drug History:
• Rivaroxaban 15mg PO OD
• Ramipril 2.5mg PO ON
• Amiodarone 200mg PO OD
• Prolia (Denosumab) 60mg SC 6 monthly
• Bisoprolol 5mg PO OD
• Furosemide 40mg PO OD
• Famotidine 20mg PO BD
• Teriparatide SC daily
• Laxido 1 sachet PO BD
• Cholecalciferol 400 units/Calcium carbonate 1.5g PO BD
• Co-codamol 30/500 1-2 tablets PO QDS PRN

Allergy History:
• Atorvastatin - constipation and headaches

Social History:
Lives with husband
Active, independent
Non smoker or drinker

On Examination:
General Appearance: Alert
Observations: HR 35 on monitor, BP 115/90, RR 14, O2 sats 98% on air, afebrile
• Cardiovascular: Good pulses, heart sounds normal
• Respiratory: Left basal crepitations
• Abdomen: Soft and non-tender
• Other: No significant peripheral oedema, no peripheral rashes, dry mucous membranes

Investigations:
• Hb 108
• Neutrophils 11.81
• WCC 13.2 (previously 5 earlier same day, likely dilutional)
• Troponin 70
• Creatinine 133 (from baseline 92)
• Potassium 5.5
• Sodium 128 (previously 132)
• CRP 7
• Urea 12.7
• LFTs normal
• Blood gas pH 7.33, otherwise reassuring

Impression:
Complete heart block secondary to digoxin toxicity with concurrent amiodarone and beta blockade
AKI stage 1
Raised TnT secondary to bradycardia and CHB

Management Plan:
1. Discussed with on-call cardiology consultant
- Happy with current management, continue isoprenaline maintaining current heart rate without further increase to avoid precipitating fast atrial fibrillation, no role for digibind
2. Add calcium and magnesium to bloods and replace if needed [/]
3. Chest X-ray [/]
4. Suspend diuretics and ACE inhibitor in context of AKI
5. If evidence of chest infection on chest X-ray, treat with antibiotics
6. Transfer to Coronary Care Unit when bed available
7. Continue amiodarone but hold bisoprolol
8. NBM overnight as may require pacing with anaesthetic support
9.

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Investigations:

Refined clerking Mon 29 September 2025 00:19

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