Cases/Cardiovascular Health

Man Contacted About An Abnormal Ecg Result — Free SCA Practice Case

Man contacted about an abnormal ECG result

Station Timer

12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Michael Dawson

Age

65 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. The patient has been asked to book this call to discuss an ECG performed after an irregular pulse was noticed at a routine medication review.

Reason for Encounter

"I got a message asking me to ring about my heart tracing. I'm not really sure what it's about — I feel fine."

Medical Records

●PMH: Hypertension. Previous ischaemic stroke (8 months ago — good recovery, no residual deficit).
●Medications: Ramipril 5 mg OD, amlodipine 10 mg OD, atorvastatin 80 mg OD, clopidogrel 75 mg OD.
●Allergies: NKDA.
●Recent notes: Routine medication review with the practice pharmacist — irregular pulse noted. ECG arranged and performed by the healthcare assistant. ECG report: irregularly irregular rhythm with absent P waves — atrial fibrillation. Observations: BP 135/85; pulse 97 bpm, irregular. CHA₂DS₂-VASc: 4. ORBIT: 1 (using bloods from 3 months ago).

Patient Script

For the friend playing the patient role

Character Overview: You are Michael, a 65-year-old man who owns a small coffee shop. You are relaxed and a little puzzled — you feel perfectly well and were not expecting anything to be wrong. You are not anxious, but you are attentive and will accept sensible advice. You are the sort of person who "didn't want to make a fuss" about the occasional fluttering you've felt.

Opening Sentence: "Hello, Doctor. I got a text asking me to call about a heart tracing I had done. To be honest I feel absolutely fine, so I'm not sure what all this is about. The pharmacist said my pulse felt a bit uneven."

History if Asked (Data Gathering Phase)

●Symptoms: "Now you mention it, I do get the odd flutter — like my heart's racing for a bit — usually when I'm sat down resting, oddly. It comes and goes. Been happening on and off for maybe five months. I didn't think anything of it."
●Associated symptoms: "No chest pain, no. I'm not short of breath, no dizziness, no funny turns. I've not been unwell or had any infections."
●The stroke: "I had a stroke about eight months ago. Frightened us all, but I made a good recovery — no lasting problems, thankfully. I've been on the clopidogrel since then."
●Blood pressure: "I've had high blood pressure for years, on tablets for it."
●How he found out: "It was just a routine medication check with the pharmacist. She felt my pulse and said it was irregular, so they did the tracing."

ICE — Ideas, Concerns, Expectations

The patient does not volunteer this information unprompted. These responses surface only when the candidate directly explores his perspective.

●Ideas: Michael has no particular theory — he genuinely thought he was well and is mildly surprised there is anything to discuss. He does not connect the flutters, the stroke, and the irregular pulse. "I honestly hadn't put two and two together. I thought the tracing would just come back normal."
●Concerns: Once it is explained, his main concern becomes whether this means he could have another stroke — that experience frightened him and he does not want to go through it again. "If I'm honest, the one thing that worries me is another stroke. That was the worst thing that's ever happened to me."
●Expectations: He wants a plain explanation of what the tracing shows and what, if anything, needs doing. He is happy to follow sensible advice. "I just want to understand what it means and what we do about it. Whatever you advise, I'll go along with."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Hypertension: "Years now. On the ramipril and amlodipine. Blood pressure's been reasonable."
●Stroke: "Eight months ago, ischaemic they said. Clot, not a bleed. Good recovery."
●Clopidogrel: "They put me on that after the stroke — the blood-thinning one, is it?"
●Statin: "Yes, the high-dose one, after the stroke."
●Adherence: "I'm good with my tablets. Never miss them."
●Family history: "My father had heart trouble in his seventies. Nothing dramatic."

Social History and Lifestyle Impact

Michael owns and runs a small independent coffee shop. He lives with his wife.

●Work: "I run a little coffee shop. On my feet a lot, long days, but I enjoy it."
●Caffeine, alcohol, smoking: "Funnily enough I only have the odd coffee myself. I don't drink alcohol at all, and I've never smoked."
●Diet and activity: "Wife keeps me on a fairly sensible diet since the stroke. I walk to work most days."
●Falls: "No, I'm steady on my feet, no falls."

If Asked — Associated Symptoms

The patient answers these only when directly asked.

●If asked about palpitations in detail (onset, duration, triggers): "They come on their own, no obvious trigger, often when I'm resting. Last a few minutes. Then settle. On and off for about five months."
●If asked about chest pain: "None."
●If asked about breathlessness: "No, my breathing's fine, even on the walk to work."
●If asked about dizziness, blackouts, faints: "No, nothing like that."
●If asked about recent illness or infection: "No, been well."
●If asked about caffeine or stimulant intake: "Barely any coffee, no energy drinks, no."
●If asked about bleeding tendency / easy bruising: "No, I don't bruise easily or anything."

Responses to Management (The Negotiation Phase)

●If the Doctor explains he has an irregular heart rhythm that raises stroke risk: "So this could cause another stroke? That's the last thing I want. What can we do to stop that?"
●If the Doctor recommends starting an anticoagulant (e.g. apixaban): "A stronger blood thinner? I'm already on the clopidogrel. Do I take both? Isn't that a lot of thinning?" (The tested point is explaining the plan to review the antiplatelet alongside the new anticoagulant, in liaison with the stroke team, rather than simply stacking them.)
●If the Doctor mentions the risk of bleeding: "What should I watch out for with a blood thinner? And what if I bang my head?"
●If the Doctor offers a rate-controlling tablet (e.g. bisoprolol): "Another tablet? What's that one for, if I feel alright?"
●If the Doctor offers a face-to-face review and blood tests: "Do you need to see me in person? What are the blood tests for?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 20 indicators checked+0−0

Positive (0/10)

Negative (0/10)

Domain 3: Relating to Others

0 / 12 indicators checked+0−0

Positive (0/6)

Negative (0/6)

Clinical Learning Points

Recognising and Diagnosing Atrial Fibrillation

●AF is an irregularly irregular rhythm with absent P waves on ECG. It is frequently found incidentally — here, an irregular pulse at a routine pharmacist review prompted the ECG.
●Paroxysmal AF may cause intermittent palpitations (often at rest) that patients dismiss, as in this case. A normal ECG between episodes does not exclude it; ambulatory monitoring may be needed if paroxysmal AF is suspected but not captured.
●Always confirm AF with an ECG before committing to long-term treatment.

Assessing Stroke Risk — CHA₂DS₂-VASc

●CHA₂DS₂-VASc estimates stroke risk in AF: Congestive heart failure, Hypertension, Age ≥75 (2 points), Diabetes, prior Stroke/TIA (2 points), Vascular disease, Age 65–74, and Sex category (female).
●A prior stroke alone scores 2 and, with his age and hypertension, gives a score of 4 — a high stroke risk for which anticoagulation is strongly indicated.

Assessing Bleeding Risk — ORBIT

●NICE NG196 recommends the ORBIT score to assess bleeding risk in people with AF being considered for anticoagulation.
●A raised bleeding score prompts attention to modifiable risk factors (blood pressure, concurrent antiplatelets, alcohol, NSAIDs) — it is not in itself a reason to withhold anticoagulation when stroke risk is high.

Anticoagulation in AF — DOAC First-Line

●For most people with AF needing anticoagulation, a direct oral anticoagulant (DOAC) — apixaban, rivaroxaban, edoxaban, or dabigatran — is first-line (NICE NG196), preferred over warfarin.
●Antiplatelet drugs (aspirin, clopidogrel) are not adequate for stroke prevention in AF and should not be used as a substitute for anticoagulation.
●Dose selection (e.g. apixaban 5 mg twice daily, reduced to 2.5 mg twice daily if criteria met — age ≥80, weight ≤60 kg, or raised creatinine) depends on age, weight, and renal function — hence the need for baseline bloods.

Managing Concurrent Antiplatelet Therapy

●A patient already on an antiplatelet (here clopidogrel for a prior stroke) who now needs anticoagulation for AF should not simply have the two stacked long-term — this substantially increases bleeding risk.
●The usual approach is to anticoagulate for the AF and review/stop the antiplatelet, unless there is a specific ongoing indication (e.g. recent coronary stent). This decision should be made in liaison with the stroke team, with interim gastroprotection considered.

Anticoagulant Safety Counselling

●Advise patients on the signs of significant bleeding (blood in urine or stool, coughing up blood, unusually heavy or prolonged bleeding, extensive bruising).
●Head injury: any significant head injury on an anticoagulant warrants emergency assessment and a CT head, even if the patient feels well, because of the risk of intracranial bleeding.

Rate Control

●For most patients with AF, rate control is the initial strategy: a beta-blocker (e.g. bisoprolol) or a rate-limiting calcium-channel blocker (diltiazem, verapamil) first-line.
●Note that dihydropyridine CCBs such as amlodipine do not control heart rate — a common point of confusion in a patient already taking one for blood pressure.
●Rhythm-control strategies and specialist referral are considered in selected patients (e.g. symptoms despite rate control, new-onset AF with a reversible cause).

Investigations and Reversible Causes

●Check thyroid function, U&E, LFTs, and FBC — to identify reversible causes (e.g. thyrotoxicosis) and to inform anticoagulant choice and dosing.
●Consider echocardiography, particularly if a murmur is heard or structural heart disease is suspected.
●Address reversible contributors: hypertension, excess alcohol, and stimulant use.

Safety-Netting and Follow-Up

●Safety-net for stroke symptoms (face, arm, speech — call 999), acute cardiac symptoms (severe chest pain, sudden breathlessness), and significant bleeding.
●Arrange follow-up (1–2 weeks) to review tolerability and bloods, and ensure coordination with the stroke team on the antiplatelet decision.

Common Candidate Mistakes in This Case

●Using an antiplatelet for stroke prevention in AF: aspirin or clopidogrel is not a substitute for anticoagulation.
●Stacking clopidogrel and a DOAC without review: failing to plan the antiplatelet review with the stroke team, leaving the patient over-anticoagulated.
●Assuming amlodipine controls the rate: not recognising that a dihydropyridine CCB does not provide rate control.
●Omitting the head-injury/CT advice: a specific and important piece of anticoagulant safety counselling.
●Alarming a well patient — or under-selling the risk: failing to pitch the explanation so a symptom-free man both grasps the importance and is not needlessly frightened.

Free MRCGP SCA practice case for GP registrars covering Man Contacted About An Abnormal Ecg Result — Cardiovascular Health. Includes candidate brief, patient script, marking scheme mapped to the RCGP SCA marking domains, and learning points. Built directly from the RCGP curriculum topic stations listed under "How this might be tested in the MRCGP SCA," part of a free library of 79 SCA practice cases for simulated consultation assessment preparation.

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