Wednesday, November 7, 2018

Assessment and plan: New onset atrial fibrillation with rapid ventricular response


Here is case one for the A&P series!

Assessment and plan: 99 yo M with PMH of ... admitted for ... is being evaluated for new onset atrial fibrillation with rapid ventricular response.

Problem 1: Atrial fibrillation

- Pt is hemodynamically stable
- CHADSVasc score: 3
- CXR: No acute changes
- EKG: Afib with RVR, rate of 130
- Echo: EF 50-55%, no valvular pathology (old date when echo was done)

- Repeat TTE
- Rate control: Metoprolol, will titrate based on BP
- Rhythm control: None
- Anticoagulation: Dabigatran

Patient seen and discussed with my attending, who agrees with the assessment and plan.

Analysis: In this A&P, I give as much information about the patient as I can in my few bullet points. Hemodynamically stable - Capturing that emergency cardioversion is not necessary. I mention the CHADSVasc score. Some residents also prefer to mention the HASBLED score to weigh the risks and benefits of anticoagulation. I try to capture relevant clinical data that I already know such as EKG (Or telemetry), CXR (because pulmonary pathology can predispose to afib) and recent echo (don't forget to put in date!)

My plan outlines what I want to do - Repeat echo to look for valvular lesions, if I am thinking of rate or rhythm control, etc. 

Quiz: If the patient was found to have mitral regurgitation on the new echo, how would my assessment and plan change?

That's all!

Hope that helps!


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