afibrvr

  • -Atrial fibrillation with RVR
  • – DDx. Given nature of presenting complaint (CC), pt was evaluated emergently for the following to determine if need for emergent diagnostics/interventions. When upon my eval, the hx/exam was exceeding clear that more emergent morbid/mortal pathologies were not in any reasonable refined ddx to this pt's presentation, further work up was not unnecessarily pursued to prevent putting pt at – in my professional opinion – were not indicated risks and outweighed benefit. Guidance was by consideration and appreciation for pt's best interest.
  • Unstable atrial fibrillation with RVR, atrial fibrillation with RVR stable, SVT,
  • – A/P:
  • – ED Course:
  • On initial presentation, patient had heart rate in the 130s, it was narrow complex on the monitor. An IV was obtained. On the monitor, the patient had a normal blood pressure and was mentating normally denying any chest pain, denies shortness of breath, denying lightheadedness or syncope. Therefore patient was deemed stable and a EKG was obtained. My interpretation of the EKG is atrial fibrillation with rapid ventricular rate. Therefore initial diagnosis is atrial fibrillation with RVR stable.
  • – Diagnostically: (aspects of evaluation emphasized given significant contribution to MDM):
  • Diagnostics were directed at elucidating potential causes of transitioning into atrial fibrillation with RVR.
  • BMP does not show any electrolyte abnormalities
  • Magnesium and phosphorus are within normal limits
  • History and examination do not suggest any acute infection
  • History and examination and chest x-ray and laboratory analysis suggest patient is euvolemic
  • From triage, troponin and BMP were sent which were both interpreted as negative.
  • – Therapeutically:
  • Planned to administer metoprolol given patient had been on metoprolol previously however patient spontaneously improved with ventricular rate to 97. Remains in atrial fibrillation
  • – MDM:
  • Suspect paroxysmal rapid ventricular rate. Patient appears to be consistently and atrial fibrillation based upon review of previous EKG and current EKG. The ventricular rate ranges between within normal limits to up to significantly elevated. Given the patient's metoprolol was just recently increased, suspect that there has not been adequate time for the metoprolol to increase for systemic effects. Therefore will advise patient to continue with metoprolol 50 mg and to follow-up with cardiology.
  • I called the patient's cardiologist and explained insurance information. The cardiologist provided an alternative cardiologist who does accept the patient's insurance and I provided the patient with this cardiologist contact information in the discharge paperwork. Patient was advised that should he be unable to obtain foll follow-up as directed, inferior but over his existing option is to return to the emergency department. Additionally the patient was advised should he have any other symptoms specifically palpitations or near syncope or chest pain or shortness of breath that the patient should return to the emergency department emergently.
  • – Diagnosis:
  • Paroxysmal atrial fibrillation with intermittent rapid ventricular response rate
  • – (most consistent with dx above wth understanding for diagnostic limitations due to emergent setting of encounter)
  • – Doubt: (evaluation was not sufficiently consistent the following entities to meet threshold for ED further diagnostics/interventions making risks outweigh benefit of further diagnostics/interventions for the patient i.e. not consistent with these etiologies. consideration included but limited to these conditions):
  • There is no evidence of any reversible causes and evaluation. Specifically there are no electrolyte abnormalities, does not appear to be hyper or hypovolemic, does not appear infected, has no toxidrome presentation.
  • – – Dispo:
  • On reevaluation, the patient remains in atrial fibrillation with normal ventricular rate. Given the patient has remained with a normal ventricular rate after an observation period in the emergency department, and patient has ability to return to the emergency department emergently should he develop sensation of palpitations.
  • Re-Evaluation
  • Remains hemodynamically stable with normal ventricular rate albeit in atrial fibrillation.

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