The Case of Rachel Stephens
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Rachel is an 84 year-old woman with hypertension and a past medical history of colon cancer. During a visit to her family physician, he assesses her pulse to be 134 and irregular. This is the first time he has seen this in her.
Part I - Initial Assessment
Her doctor asks her about symptoms. She has not had any chest pain, though admits worsening shortness of breath over the past few months. She has also developed a non-productive cough and has noticed swelling in her legs.
Her past medical history is significant only for mild asthma, controlled with ventolin as needed.
What conditions are you concerned about? What is the concern?
Atrial fibrillation is the most likely diagnosis, along with potential heart failure.
The immediate concern is of embolic stroke. Worsening heart disease carries substantial morbidity and mortality, depending on its cause.
What are the potential causes of her condition?
Atrial fibrillation can be caused by the following:
What investigations are required?
Part B
Once in the emergency department, Ms Stephens gets an ECG, chest X-ray, and bloodwork.
The following ECG is obtained:
What treatment is indicated acutely?
What should her long term treatment be?
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