Summary of Common Conditions Seen in OSCEs
| Condition | Key points in history | Key points in management |
| Atrial fibrillation | Elderly patientPast medical history of ischaemic heart disease, hypertension, congestive heart failure, mitral valve diseaseRecent onset coinciding with symptoms suggestive of lower respiratory tract infection | See Chapter 65 on ECGs |
| Supraventricular tachycardia | Past medical history of COPD (predisposes to multifocal atrial tachycardia)Associated with symptoms of compromise, e.g. chest pain, shortness of breath, pre-syncopePrevious episodes terminated by vagal manoeuvres, e.g. blowing the nose | See Chapter 65 on ECGs |
| Ventricular tachycardia | Symptoms of compromise, e.g. chest pain, shortness of breath, pre-syncope, cold peripheries, sweatingHistory of recent myocardial infarctionPast medical history of ischaemic heart diseaseFamily history of sudden death, known long QT syndrome | See Chapter 65 on ECGs |
| Thyrotoxicosis (causing sinus tachycardia or atrial fibrillation) | Weight loss, increased appetite, heat intolerance, diarrhoea, tremor, mood disturbancePast medical history of thyroid diseasePast medical history of other autoimmune disease (insulin-dependent diabetes mellitus, vitiligo, Addison’s disease, pernicious anaemia, etc.) | Follow protocol for atrial fibrillationMedical/surgical correction of thyrotoxicosis |
| Hypertrophic obstructive cardiomyopathy (HOCM) | Family history of sudden deathCollapse while playing sportfamily history of HOCM | AmiodaroneAnticoagulate if paroxysmal atrial fibrillationImplantable defibrillatorSeptal myomectomy |
| Excess caffeine intake | History of excessive caffeine intake (definition of ‘excessive’ varies from patient to patient)No symptoms suggesting compromisePalpitations self-limitingPast medical history of cardiac or thyroid disease | Decrease caffeine intakeRule out cardiac and thyroid-related causes |
| Phaeochromocytoma | Triad of episodic headache, sweating, fast palpitationsWeight lossSymptoms of anxietyNB. This must be ruled out before ascribing symptoms to generalised anxiety disorder | Urgent referral to endocrine surgeonsInvestigate for multiple endocrine neoplasia type 2, neurofibromatosis, von Hippel–Lindau syndrome |
| Simple anxiety | Associated with important/stressful eventNo symptoms of compromiseNo history of cardiac or thyroid disease | ReassuranceBehavioural therapy/cognitive-behavioural therapyBeta-blockers if severe symptoms |
| Fever | Localising symptoms of infection (e.g. cough, earache)First episode or episodes only coincide with febrile illness | Antipyrexial medication (e.g. paracetamol) |
| Generalised anxiety disorder | Associated with important/stressful eventNo symptoms of compromiseNo history of cardiac or thyroid diseasePast medical history of depressionAvoidance of predisposing situations | Referral to psychiatryBeta-blockers for symptom control |
| Ventricular ectopics | Recent myocardial infarctionPast medical history of ischaemic heart diseaseDescription of missed beat followed by heavier beat | Usually no treatment required if asymptomatic and infrequentAmiodarone if >10/min or symptomatic |
| Pacemaker failure | Past medical history of pacemaker insertion | Replacement/repair of pacemaker |
| Hypoglycaemia | Associated with sweating, anxiety, hunger, tremor, dizzinessPast medical history of diabetes mellitusDrug history of hypoglycaemic medication (not metformin)History of liver disease, Addison’s disease | Oral sugar followed by slow-release carbohydrateIntravenous dextrose (if unable to swallow) |
Relevant Investigations You May Need to Discuss at This Station
| Investigation | Justification |
| ECG | Instant detection of underlying rhythm |
| Detection of long QT syndrome | |
| Full blood count | Anaemia precipitates palpitations |
| High white cell count suggests infection | |
| Thyroid function tests | Diagnosis of thyrotoxicosis |
| Blood glucose | Diagnosis of hypoglycaemia |
| Risk assessment for cardiovascular disease | |
| Us+Es | Hypokalaemia/hyperkalaemia can cause fatal arrhythmias |
| Mg and Ca | Low levels of Ca and Mg predispose to long QT syndrome and therefore polymorphic ventricular tachycardia |
| 24-hour ECG monitoring | Identification of paroxysmal arrhythmias |
| Echo | Identification of structural heart disease, e.g. HOCM or mitral stenosis, that may predispose to arrhythmias |
| Exercise ECG | Detection of arrhythmias precipitated by ischaemic heart disease |
Hints and Tips for the Exam
Palpitations are an extremely common complaint in general practice and A&E settings so this is a popular station in the OSCE exam. The underlying causes range from being benign (e.g. anxiety prior to an OSCE) to being potentially catastrophic (e.g. paroxysmal ventricular tachycardia after a myocardial infarction). This can make the task of taking a history in 5 minutes challenging. However, your task will be made easier if you remember the following six tips:
• The importance of starting with an open question to get the patient talking cannot be stressed enough. The information from this alone will often go a long way towards formulating a differential diagnosis to guide further history-taking BUT …
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