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Old 06-25-2011
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EKG CCS: Atrial Fibrillation

Location: Emergency Room
Cc: 65 years old man with shortness of breath and palpitation
Vital signs: B.P. 150/90 mmHg, Pulse- 140/minute, irregularly irregular, Temperature- 98.60F, RR-
20/minute, weight- 160 lb.
History of Present Illness (HPI): 65 years old male presented with the complaint of shortness of breath
and palpitation for last 1 day. He has decreased exercise tolerance, feels weak and often feels dizzy. He
denied syncope, cough, chest pain or leg swelling. He has smoked 1/2 pack a year for last 40 years,
drinks alcohol occasionally in parties and festivals. He never used any street drugs.
Past Medical History: Hypertension diagnosed for last 20 years
Order: Pulse oximetry-stat
[Result is available within a minute for patients in emergency room. Results automatically pop up. If
patient is saturating above 90% click continuous, otherwise stop and start on oxygen inhalation continuous
and then again check the pulse ox.]
Cardiac monitor-stat, Blood pressure monitoring, continuous-stat, IV access-stat, CBC-stat, CHEM 8-
stat, PT-stat, PTT-stat, Cardiac enzyme- stat and q8 hourly
Oxygen saturation: 92% on room air
Cardiac monitor- Atrial fibrillation
Blood pressure-140/90 mmHg
Other lab result will take time so, start examination.
Focal examinations: General, HEENT, skin, abdomen, respiratory, cardiac, extremity
Only positive finding on examination is bilateral basal crackles in lung field, heart sound S1, S2
irregularly, irregular
Note: Findings on exam and cardiac monitor suggest that it is Atrial fibrillation. To confirm we always
do 12 lead EKG
Order: EKG 12 lead (after ordering move the clock to get EKG result), Chest x-ray: Portable
EKG: Atrial fibrillation
Note: Now your diagnosis of Atrial fibrillation is confirmed. Your patient vital are stable except that he
has tachycardia. Now we have to control the heart rate with IV Metoprolol or Diltiazem or Verapamil or
Digoxin and start the IV heparin to prevent thromboembolism. Before we start heparin we always do
rectal exam to rule out occult GI bleed and draw labs for CBC and PT/PTT which is already drawn in
this patient.
Order: Diltiazem IV bolus, Rectal exam
Follow up rectal exam result: No nodularity or mass, negative for occult blood
Heparin IV: Continuous
PT/PTT: Q6 hourly
Diltiazem IV continuous
Transesophageal echocardiogram (TEE)
Thyroid function test (Order TSH, Free T4) {It takes about 3 days for these test results}
Follow up routine labs and TEE report
TEE: Left atrial enlargement, No visible thrombus, left ventricular hypertrophy with ejection fraction of
55%. No valvular abnormality.
Cardioversion, Synchronous
Result: 200 J applied to chest, patient converted to sinus rhythm, has slight discomfort in the chest.
Order: Check cardiac monitor, EKG 12 lead: Result: Normal sinus rhythm
Change location: Unit (Patient should be in the monitored bed)
Order: Cardiology consult: Patient with atrial fibrillation, converted to sinus rhythm, please evaluate for
further management.
Now you have converted patient to sinus rhythm, patient is on IV heparin, Diltiazem. You should move
the clock for next day round at 9AM.
End the case: Diagnosis: Atrial Fibrillation
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The above post was thanked by:
hionlyf (07-31-2012)


Cardiology-, EKGs-, Step-3-Questions

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