ccs case 1 - aphrodite

[ArchivalUser]

32 yo F presents with occasional palpitation,chest pain and dizziness.She also reports shortness of breath and chest tighness during attacks.
VS-
P 90-200 (variable)
BP 125/75

RR 20
Mild cyanosis
HEENT-WNL
Lungs-bibasilar crackles
CV-irregularly irregular,tachycardia
Abd-wnl
Ext-wnl

how do you manage it?do you have to give the drug dosage too?how long will you observe her in ER before transferring to ICU?

[ArchivalUser]

Ok...I'll take a shot at this:

DDx:
Afib, MFAT, thyrotoxicosis, pneumothorax, esophageal tear (very unlikely)

Initial Tests
EKG, CBC, SMA-7, Thyroid Panel, CXR, FOBT

Initial management: Amioadaron/Ca Channel blocker,

[ArchivalUser]

yo B, what's your input...come on, I don't have all day

[ArchivalUser]

ER-
order-IV access and N/S
oxygen
EKG
echo
Lab-complete metab panel?? thyroid panel
cbc


tretment
IV amiodarone
synchronised cardioversion
anticoag??before cardioversion?? (we dont know how long she has been having it....generally anticoag recommended if fib>48 hrs or unknown duration.....or maybe we could do a transesophageal echo to rule out clots prior to starting cardioversion??)

then how long do i watch her in ER??when should i shift her to ICU?
in ICU i would put her on continous ekg monitor,bp continue with anticoag (how long? 2 weeks?)

when to discharge her?
follow her up in a week?and counsell during discharge...............i dunno

help guys!!

[ArchivalUser]

saturation
oxygen by face mask
EKG with monitoring
What is the cause of palpitations (ischemia, thyrotoxicosis, alcohol, dyselectrolytemia, COPD)
Immediate step, CCB and consider heparin after FOBT.
Do SMA 7, TSH, 2D Echo (maybe TEE to R/O intramural thrombus), CxR

Observe in ER till pulse rate is controlled, though AF might persist. Consider long term anticoagulation with Electrical cardioversion .

[ArchivalUser]

Pulse oxy
Oxygen
IV access
EKG 12 lead stat

Get EKG result (AF)
Diltiazem IV, continuous

cbc,bmp stat
cxr stat
cardiac enzymes stat
troponin I stat
TSH stat
coagulation profile stat
FOBT ( pt might need heparin)

(after ordering this you can move the patient to ward, if she is stable)

Move patient to ward
vitals and pulse oxi q4 hrs
bedrest with bathroom preveliges
cardiac monitor
diet normal
ECHO
heparin iv continuous
PTT q6 hrs
CBC daily ( HIT)

Check interval history
patient HR returned to normal
D/C diltiazem

Next day
INR (>2)
start warfarin

Patient is stable then discharge.
schedule appointment on 3rd day.

Review order
daily PT/PTT
pateint education
treatment for underlying disorder.

EXIT Case

Atrial Fibrillation

Please let me know if these steps are correct.