Cases/Cardiovascular Health

Woman Found to Have A Low Heart Rate At Pre-operative Assessment — Free SCA Practice Case

Woman found to have a low heart rate at pre-operative assessment

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

Maureen Ellis

Age

68 years

Consultation Type

Video

Age

Situation

Video Consultation.

Reason for Encounter

"I went for my check-up before my knee operation and they said my pulse was too slow and I had to see my GP. Now I'm terrified they're going to cancel my operation. I've waited two years for this knee."

Medical Records

●PMH: Osteoarthritis, right knee (listed for total knee replacement). No other significant history.
●Medications: None regular. Occasional paracetamol for knee pain.
●Allergies: NKDA.
●Recent note (pre-operative assessment clinic, 5 days ago): "Heart rate 46 bpm, regular. BP 132/78. Asymptomatic. No murmur documented. Advised to see GP for review of bradycardia before proceeding. ECG not performed at this visit." No bloods on file within the last 12 months.

Patient Script

For the friend playing the patient role

Character Overview: You are Maureen, a 68-year-old retired school administrator. You are anxious and slightly tearful about the possibility of losing your operation slot — this is the dominant emotion of the consultation. You feel completely well in yourself and cannot understand what the fuss is about. You have been in pain and waiting a long time, and the fear of being "sent to the back of the queue" is overwhelming everything else.

Opening Sentence: "Hello, Doctor. I'm in a bit of a state, to be honest. At my pre-op they said my heart rate was too slow — forty-something — and I've got to be checked before they'll do my knee. Please tell me this doesn't mean they'll take me off the list. I've waited two years and I can barely walk."

History if Asked (Data Gathering Phase)

●Symptoms: "That's the thing — I feel completely fine. No dizziness, no fainting, no palpitations. I didn't even know my pulse was slow until they told me."
●The knee: "It's my right knee. Bone on bone, they said. I'm on paracetamol and it barely touches it. I've stopped going out much because of it."
●Exercise tolerance: "I can't walk far because of the knee, but my breathing's fine — it's the knee that stops me, not being out of puff."
●Any past heart problems: "Never. Never had anything wrong with my heart. Blood pressure's always been normal."
●Fitness background: "I used to be quite the runner in my forties and fifties — did a few half marathons. Not for years now though, with the knee."

ICE — Ideas, Concerns, Expectations

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

●Ideas: Maureen has no real idea why her heart rate is slow and assumes it must be "something serious" because they stopped her operation over it. "I don't know what a slow heart even means. But it must be bad if they won't operate, mustn't it?"
●Concerns: Her overwhelming concern is losing her place on the waiting list and being back in limbo with an unbearable knee. The heart itself worries her far less than the delay. "Honestly, Doctor, the heart doesn't scare me half as much as the thought of them cancelling. I can't face another two years like this."
●Expectations: She wants to be told she can still have her operation, and quickly. "I just want to know I'm still having my knee done. That's all I care about."

If Asked — Medical History and Medications

The patient confirms these details only when directly asked.

●Past medical history: "Nothing really. The knee, and that's it. I've been lucky healthwise."
●Medications: "Just paracetamol when the knee's bad. Nothing regular. No heart tablets, no blood pressure tablets."
●Beta-blockers or other rate-slowing drugs: "No, nothing like that. I don't take anything for my heart."
●Thyroid: "Not that I know of. Nobody's ever mentioned my thyroid."
●Family history: "My mother had a pacemaker in her seventies, come to think of it. I don't know why."

Social History and Lifestyle Impact

Maureen is a retired school administrator. She lives alone since being widowed three years ago. Her daughter lives nearby.

●Living situation: "I live on my own. My daughter's close by and pops in. The knee's made me quite housebound, which I hate."
●Activity: "I was always active — walking, running when I was younger. This knee has taken all that away from me."
●Smoking and alcohol: "Never smoked. A sherry at Christmas, that's about it."
●Mood: "I'll admit the waiting and the pain have got me down a bit. I'm not myself."

If Asked — Associated Symptoms

The patient answers these only when directly asked.

●If asked about dizziness or light-headedness: "No, none at all."
●If asked about fainting or blackouts: "Never fainted in my life."
●If asked about palpitations or awareness of the heartbeat: "No, I don't feel my heart at all."
●If asked about chest pain: "No chest pain, no."
●If asked about breathlessness: "No — it's honestly just the knee that limits me, not my breathing."
●If asked about tiredness / fatigue: "A bit tired, but I put that down to the pain keeping me up at night."
●If asked about cold intolerance, weight gain, constipation, dry skin (thyroid screen): "No, nothing like that. Weight's steady, no problems there."
●If asked about ankle swelling: "No swelling."

Responses to Management (The Negotiation Phase)

●If the Doctor reassures her she will not be removed from the list: "Do you promise? So it's just a delay while you check, not a cancellation?" (The tested point is honest reassurance — she will not be struck off, but surgery is deferred pending safe assessment — without over-promising a specific timeline.)
●If the Doctor arranges an ECG and monitoring: "What are all these tests for? What are you actually looking for?"
●If the Doctor mentions possibly involving cardiology or the anaesthetist: "Does that mean it's serious? Why do you need a heart specialist?"
●If the Doctor raises her past running: "What's my old running got to do with my heart rate now?"
●If the Doctor gives safety-netting: "So what would mean I need to be seen urgently?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

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

Defining and Interpreting Bradycardia

●Bradycardia is a resting heart rate below 60 bpm; the clinical significance depends far more on symptoms and the underlying rhythm than on the number itself.
●Asymptomatic sinus bradycardia in a well person is frequently benign and needs no treatment; symptomatic bradycardia (syncope, presyncope, fatigue, breathlessness, or haemodynamic compromise) requires assessment and may need intervention.
●The first task is always to establish whether the patient is symptomatic — this drives urgency.

Causes of Bradycardia

●Physiological: high vagal tone in athletes and the physically fit — a benign, often lifelong finding (relevant to this former distance runner).
●Drugs: beta-blockers, rate-limiting calcium-channel blockers (diltiazem, verapamil), digoxin, some antiarrhythmics — the commonest reversible cause; confirm the patient is not taking them.
●Metabolic/endocrine: hypothyroidism, hypothermia, electrolyte disturbance (hyperkalaemia).
●Cardiac conduction disease: sinus node dysfunction (sick sinus syndrome) and atrioventricular block — these carry the risk that may need pacing.
●A family history of pacemakers can point towards inherited conduction disease.

Investigating Incidental Bradycardia

●12-lead ECG is the essential first investigation: it distinguishes benign sinus bradycardia from heart block or sinus node dysfunction.
●Ambulatory ECG monitoring (24-hour or longer, or a patient-activated recorder) captures rate variability, pauses, and intermittent conduction abnormalities that a single ECG may miss.
●Bloods: thyroid function tests, U&E (electrolytes), and FBC; add others as the picture dictates.

When to Refer and Who Decides Surgical Fitness

●Refer to cardiology for high-grade AV block (second-degree Mobitz II, complete heart block), significant pauses, symptomatic bradycardia, or sinus node dysfunction — pacing may be indicated.
●Benign asymptomatic sinus bradycardia with a normal ECG usually needs no cardiology input.
●The anaesthetic and pre-operative team make the final decision on fitness for surgery; the GP's role is to investigate, identify and treat reversible causes, and communicate findings back.

Pre-operative Optimisation, Not Obstruction

●An incidental abnormality found at pre-assessment triggers optimisation so surgery can proceed safely — it is not a reason to remove a patient from the waiting list.
●Surgery may be temporarily deferred pending assessment; the patient retains their place. Communicating this accurately is central to managing the patient's distress.
●Where a reversible cause (e.g. hypothyroidism) is found and treated, the bradycardia may resolve and the pathway to surgery clears.

Managing the Patient While They Wait

●The presenting problem (disabling knee osteoarthritis) does not pause during the cardiac work-up: review analgesia, function, and mood, and support the patient through the delay.
●Recognise the psychological impact of prolonged waiting and reduced mobility, including low mood and social isolation.

Safety-Netting in Bradycardia

●Advise the patient to seek urgent assessment (999 or same-day) if they develop blackouts, dizziness, chest pain, or breathlessness — the symptoms that convert benign asymptomatic bradycardia into an urgent problem.

Communication and Care Coordination

●Feed ECG, monitoring, and blood results back to the pre-operative and surgical teams promptly to avoid duplication and further delay.
●Arrange clear follow-up so results are reviewed and the plan progresses.

Common Candidate Mistakes in This Case

●Missing that she is asymptomatic: not establishing the absence of syncope, dizziness, or breathlessness, and so misjudging urgency in either direction.
●Failing to arrange an ECG: not recognising that no ECG has been done and that distinguishing sinus bradycardia from heart block is the pivotal step.
●Overlooking reversible causes: not screening for drugs or hypothyroidism.
●Mishandling the reassurance: either telling her the operation is cancelled, or over-promising it will proceed on a fixed date — both damaging.
●Ignoring the real agenda: conducting a competent cardiac assessment while never addressing her overwhelming fear about the waiting list, failing Domain 3.

Free MRCGP SCA practice case for GP registrars covering Woman Found to Have A Low Heart Rate At Pre-operative Assessment — 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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