Consultant Cardiology oral assessment prep

Knowledge: An irregularly irregular broad-complex tachycardia with varying QRS morphology and very short RR intervals is pre-excited atrial fibrillation conducting antegradely down an accessory pathway, not atrial fibrillation with bundle branch aberrancy, in which the QRS morphology would be fixed.

Management: I would call for the resuscitation team and defibrillator, secure the airway and give oxygen, obtain intravenous access and apply pads while confirming the rhythm on a printed 12-lead where possible. Given hypotension and reduced consciousness I would proceed immediately to synchronised DC cardioversion under short-acting sedation with anaesthetic support, starting at a high biphasic energy, and be prepared to deliver an unsynchronised shock if the rhythm degenerates to ventricular fibrillation.

Ethics and communication: A drug given in good faith has caused a serious, potentially fatal deterioration, and my obligation is open disclosure: once he is stable and able to understand, I would explain to the patient and, with his consent, his family exactly what happened, why the drug was contraindicated in his rhythm, what we did to correct it and what we are doing to prevent recurrence, offering a sincere apology without deflecting responsibility onto the individual doctor.

Reference: 2019 ESC Guidelines for the management of patients with supraventricular tachycardia (Brugada J et al., European Heart Journal, 2020) and the 2022 ESC Guidelines for the management of patients with ventricular arrhythmias and the prevention of sudden cardiac death

Knowledge: This is an acute Stanford type A aortic dissection, DeBakey type I, and it is a surgical emergency with an untreated mortality of approximately one to two per cent per hour in the first 48 hours, so time to the operating theatre is the single greatest determinant of survival.

Management: I would move him to a monitored resuscitation bay with an arterial line placed in the arm with the higher pressure, give adequate opioid analgesia because pain drives the sympathetic surge, and start intravenous labetalol or an esmolol infusion titrated to a heart rate of 60 or below, adding sodium nitroprusside or another vasodilator only once rate control is achieved.

Ethics and communication: He was competent twenty minutes ago and is now not, so I must act under the emergency doctrine of necessity in his best interests for immediately life-saving treatment and transfer, which does not require signed consent, and I would document precisely why consent could not be obtained, what I did and at what time.

Reference: 2022 ACC/AHA Guideline for the Diagnosis and Management of Aortic Disease (Isselbacher EM et al., Circulation, 2022) and the 2014 ESC Guidelines on the diagnosis and treatment of aortic diseases

Knowledge: The muffled click, restricted leaflet motion and rising gradient point to obstructive mechanical prosthetic valve thrombosis, which is a life-threatening emergency, and the pathophysiological explanation is inadequate anticoagulation in the hypercoagulable state of pregnancy compounded by unmonitored, self-reduced low molecular weight heparin.

Management: I would admit her to a high dependency area with continuous maternal and fetal monitoring, involve obstetrics, cardiac surgery, anaesthesia, haematology and neonatology immediately as a pregnancy heart team, and start intravenous unfractionated heparin titrated by APTT while imaging is arranged. Transoesophageal echocardiography plus fluoroscopy defines thrombus size, mobility and leaflet excursion.

Ethics and communication: This is a case where maternal and fetal interests genuinely diverge and my duty is to the pregnant woman as my patient, so I must present the anticoagulation options honestly, including that the regimen that best protects her life carries fetal risk, and support her to make an informed choice rather than making it for her.

Reference: 2018 ESC Guidelines for the management of cardiovascular diseases during pregnancy (Regitz-Zagrosek V et al., European Heart Journal, 2018) and the 2021 ESC/EACTS Guidelines for the management of valvular heart disease

Knowledge: Probity is a core element of professional practice and falsification of a training record is a serious matter of dishonesty, not an administrative shortcut, and it matters precisely because credentialing bodies and patients rely on the accuracy of these records to know who is competent to do what. Countersigning a record I know to be false would make me a party to the dishonesty and would itself be a disciplinary matter, and it would breach my own registration conditions under the DHA, SCFHS or equivalent authority.

Management: I would decline to countersign, and I would say so clearly, kindly and without ambiguity, explaining why rather than simply refusing. I would arrange a private, documented meeting with him at a time when neither of us is on call, allow him to give his full account, and take contemporaneous notes; I would advise him to seek support from a trusted senior colleague or his professional association and to consider self-reporting, which is always viewed more favourably than discovery.

Ethics and communication: The central obligation is to patients and to the integrity of the credentialing system, and that duty outranks loyalty to a colleague and my sympathy for his visa and family circumstances, which are real but cannot be allowed to purchase a false signature. Equally, professionalism requires that I treat him fairly: he is entitled to know the concern, to respond, to representation and to due process, and I must not gossip, prejudge or humiliate him.

Reference: DHA Health Professionals Code of Conduct and Ethics and the DHA Manual for Professional Assessment (2025); General Medical Council, Good Medical Practice (2024), domains on honesty and integrity and on raising and acting on concerns