WBR0994

Author	[[PageAuthor::Mohamed Moubarak, M.D. [1]]]
Exam Type	ExamType::USMLE Step 3
Main Category	MainCategory::Emergency Room
Sub Category	SubCategory::Cardiovascular
Prompt	[[Prompt::A 56 year-old female comes to ED complaining of sudden onset of dizziness and palpitation, and light headedness. These symptoms have been occurring frequently for the past 2 days, last for few minutes, and resolve spontaneously. She has a history of hypertension, and ischemic heart disease. Her current medications are daily aspirin, metoprolol, and hydrochlorothiazide. On examination, her heart rate is 110 bpm and shows irregular irregularity, blood pressure is 130/80 mmHg, temperature is 37 C (98.6 F), and respiratory rate is 18/min. Her EKG shows atrial fibrillation. What is the best next step in the management of this patient?]]
Answer A	AnswerA::Intravenous Diltiazem drip
Answer A Explanation	[[AnswerAExp::Correct Intravenous rate control medications such as diltiazem should be administered in ED]]
Answer B	AnswerB::Aspirin and follow up in the office
Answer B Explanation	[[AnswerBExp::Incorrect Stable patients should have their ventricular rate controlled first. Aspirin is used more with alone fibrillation to prevent stroke, but oral anticoagulants are recommended in paroxysmal atrial fibrillation.]]
Answer C	AnswerC::Oral Amiodarone and follow up in the office
Answer C Explanation	[[AnswerCExp::Incorrect Amiodarone is the recommended first line antiarrhythmic drug to maintain the normal sinus rhythm after being controlled in ED first.]]
Answer D	AnswerD::Reassurance and follow up in the office
Answer D Explanation	[[AnswerDExp::Incorrect This patient needs to have rate control medications and further evaluation.]]
Answer E	AnswerE::Refer the patient to a Cardiologist
Answer E Explanation	AnswerEExp::This patient should be managed in ED. Intravenous rate control medications should be administered in ED such as beta blockers, calcium channel blockers (diltiazem), or digoxin.
Right Answer	RightAnswer::A
Explanation	[[Explanation::The patient in this case is the classic presentation of paroxysmal atrial fibrillation, which present with recurrent episodes of palpitation which resolve spontaneously. Intravenous rate control medications should be administered in ED such as beta blockers, calcium channel blockers (diltiazem), or digoxin. Educational Objective: References: ]]
Approved	Approved::No
Keyword	[[WBRKeyword::paroxysmal atrial fibrillation]]
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