Summary of Common Conditions Seen in OSCEs
| Condition | Key points in history | Key points in management |
| Atrial fibrillation | Elderly patient Past medical history of ischaemic heart disease, hypertension, congestive heart failure, mitral valve disease Recent 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-syncope Previous 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, sweating History of recent myocardial infarction Past medical history of ischaemic heart disease Family 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 disturbance Past medical history of thyroid disease Past medical history of other autoimmune disease (insulin-dependent diabetes mellitus, vitiligo, Addison’s disease, pernicious anaemia, etc.) | Follow protocol for atrial fibrillation Medical/surgical correction of thyrotoxicosis |
| Hypertrophic obstructive cardiomyopathy (HOCM) | Family history of sudden death Collapse while playing sport family history of HOCM | Amiodarone Anticoagulate if paroxysmal atrial fibrillation Implantable defibrillator Septal myomectomy |
| Excess caffeine intake | History of excessive caffeine intake (definition of ‘excessive’ varies from patient to patient) No symptoms suggesting compromise Palpitations self-limiting Past medical history of cardiac or thyroid disease | Decrease caffeine intake Rule out cardiac and thyroid-related causes |
| Phaeochromocytoma | Triad of episodic headache, sweating, fast palpitations Weight loss Symptoms of anxiety NB. This must be ruled out before ascribing symptoms to generalised anxiety disorder | Urgent referral to endocrine surgeons Investigate for multiple endocrine neoplasia type 2, neurofibromatosis, von Hippel–Lindau syndrome |
| Simple anxiety | Associated with important/stressful event No symptoms of compromise No history of cardiac or thyroid disease | Reassurance Behavioural therapy/cognitive-behavioural therapy Beta-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 event No symptoms of compromise No history of cardiac or thyroid disease Past medical history of depression Avoidance of predisposing situations | Referral to psychiatry Beta-blockers for symptom control |
| Ventricular ectopics | Recent myocardial infarction Past medical history of ischaemic heart disease Description of missed beat followed by heavier beat | Usually no treatment required if asymptomatic and infrequent Amiodarone if >10/min or symptomatic |
| Pacemaker failure | Past medical history of pacemaker insertion | Replacement/repair of pacemaker |
| Hypoglycaemia | Associated with sweating, anxiety, hunger, tremor, dizziness Past medical history of diabetes mellitus Drug history of hypoglycaemic medication (not metformin) History of liver disease, Addison’s disease | Oral sugar followed by slow-release carbohydrate Intravenous 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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