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  #1  
Old 01-31-2015
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Default A cardiology question in USMLE

A 57 year-old man presents to the ER complaining of sudden dizziness and heart racing for 2 hours. He is a CEO of a big corporation and those symptoms started during a stressful meeting . At first, he felt irregular heart beats and ignored it but he felt dizzy soon after and his staff drove him to the ER. There is no chest pain, shortness of breath or loss of consciousness. His vital signs are temp 97.8 F, Pulse 138/min and irregular, blood pressure 107/60 and oxygen saturation is 96% on room air. His ECG is shown on the diagram.

What is the appropriate treatment to improve his symptoms in this current situation?

A- Metoprolol

B- Aspirin

C- Heparin

D- Cardioversion

E- refer to cardiologist

ECG and coming answer at this link : http://medical-usmle.com/?p=703
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  #2  
Old 02-01-2015
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Neuro

The patient has AFib with fast ventricular response. It seems like the best responses are either cardioversion or call a cardiologist.
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  #3  
Old 02-01-2015
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Default A Fib

This person has non-complicated A Fib. Why do you think that he has fast ventricular response? He is stable with no chest pain, SOB or loss of consciousness. I think the best answer is A beta blocker to slow the heart rate and if fails he might need cardioversion or cardiologist.
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  #4  
Old 02-01-2015
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It should be metoprolol to stabilize heart rate as this is the most appropriate "current management for his symptoms"
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  #5  
Old 02-02-2015
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Default

Patient has AFib with RVR because his heart rate > 100. Metoprolol might be useful. However, he is hypotensive, which according to http://wikem.org/wiki/Atrial_Fibrillation_with_RVR is a contraindication. Therefore, it's either cardioversion or call the cardiologist
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  #6  
Old 02-02-2015
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He is not hypotensive his symptoms are due to afib. 107/60 is not hypotension
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  #7  
Old 02-02-2015
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The patient has a typical presentation of uncomplicated atrial fibrillation. His dizziness, irregular heart rate and low blood pressure as well as his ECG abnormalities support the diagnosis. His ECG shows absent P wave and irregular P-R intervals. His is also stable i.e. No chest pain, no SOB and no loss of consciousness.
This patient‘s symptoms are mainly caused by the rapid irregular heart rate. Beta blockers are the first line of treatment to slow heart rate and to improve his symptoms.
One of the features accompanied with A Fib is stasis of blood within the right atrium. For this reason and also because the patient is stable, cardioversion is not recommended as the first line of treatment in this case.
There is no rule of aspirin or heparin at this time though he might need a long term prescription of anticoagulant.
Reference to a cardiologist is premature at this point as primary care physician can provide the initial treatment for his condition.
The correct answer is A
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