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| {{familytree | | | | | | | A01 | | | | | | |A01=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Identify cardinal symptoms and signs that increase the pre-test probability of palpitations'''<br>
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| Symprtoms:<br>
| | {| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;" |
| ❑ Flip-flopping of the chest<br>
| | ! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Bacterial infection}} |
| ❑ Rapid fluttering of the chest<br>
| | |- |
| ❑ Pounding in the neck<br>
| | | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen''''' |
| ❑ Pulsation palpitations <br>
| | |- |
| Signs:<br>
| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Penicillin VK]] 500 mg PO q6-8h for 7 to 10 days, twice daily for mantainance'''''<BR> OR <BR>'''''[[Amoxicillin]] 500 mg PO q8h for 7 to 10 days, twice daily for mantainance''''' |
| ❑ Increased heart rate with regular or irregular rhythm<br>
| | |- |
| ❑ Cardiological findings suggestive of a cardiological disease<br>
| | | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Alternative Regimen''''' |
| : ❑ [[Murmurs]]<br>
| | |- |
| : ❑ [[S3]] sound<br> | | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Clindamycin]] 150-300 mg PO q6h '''''<BR> OR <BR>'''''[[Vibramycin]] 100 mg PO q24h '''''<BR> OR <BR>'''''[[Erythromycin]] 400 mg PO q8h''''' <BR> OR <BR> ▸ '''''[[Azithromycin]] 500 mg PO q24h for 1 day, then 250 mg PO q24h for 4 days''''' |
| : ❑ [[Muffled heart sounds]]<br> | | |- |
| : ❑ Displaced [[apex beat]]</div>}}
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| {{familytree | | | | | | | |!| | | | | | |}}
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| {{familytree | | | | | | | B01 | | | | | | |B01=<div style="float: left; text-align: left; width: 16em; padding:1em;">'''Does the patient have any of the followign findings that require urgent management?'''<br>
| | {| style="float: left; cellpadding=0; cellspacing= 0; width: 400px;" |
| ❑ Palpitations asociated with [[syncope]] (suggestive of [[VT]] of [[structural heart disease]])
| | ! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Fungal infection}} |
| ❑ [[Chest discomfort]] suggestive of [[ischemia]]<br>
| | |- |
| ❑ Decompensated [[heart failure]]<br>
| | | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen''''' |
| ---- | | |- |
| ❑ Consider [[Cardioversion|electrical cardioversion]]</div>}}
| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Nistatin oral suspention]] 5-15 ml q6h '''''<BR> OR <BR>'''''[[Clotrimazole]] 10 mg PO q8h for 7 to 10 days'''''<BR> OR <BR>'''''[[Fluconazole]] 200 mg every two days, then 100 mg q24h''''' |
| {{familytree | | | | |,|-|-|^|-|-|.| | |}}
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| {{familytree | | | | W01 | | | | W02 | | | | |W01='''Yes'''|W02='''No'''}}
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| {{familytree | | | | |!| | | | | |!| | }}
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| {{familytree | | | | Y01 | | | | Y02 | | | | Y01='''Does the patient have any of the following findings suggesting of hemodynamic instability?'''|Y02='''[[SandboxAlonso#Complete diagnostic approach|Continue with the complete duagnostic apporoach shown below]]'''}}
| | | style="float: left; cellpadding=0; cellspacing= 0; width: 400px;" |
| ❑ [[Hemodynamic instability]]<br>
| | ! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viral infection}} |
| ❑ [[Hypotension]]<br>
| | |- |
| ❑ [[Cold extremities]]<br>
| | | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen''''' |
| ❑ [[Cyanosis|Peripheral cyanosis]]<br>
| | |- |
| ❑ [[Mottling]]<br>
| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Acyclovir]] 5-15 ml q6h '''''<BR> OR <BR>'''''[[| style="background: #FFFFFF;" |
| ❑ [[Altered mental status]]<br>
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| {{familytree | | | | | |,|-|^|-|.| | | |}}
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| {{familytree | | | | | | C01 | | C02 | | | |C01={{fontcolor|#F8F8FF|'''Yes'''}}|C02=<div style="text-align: center; background: #FFFFFF; height: 25px; line-height: 25px;">'''No'''</div>}}
| | ! style="height: 30px; line-height: 30px; background: #4479BA; border: 0px; font-size: 100%; text-shadow: 0 -1px 0 rgba(0, 0, 0, 0.5);" align=center | {{fontcolor|#FFF|Viral infection}} |
| {{Familytree | | | | | |!| | | |!| | | |}}
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| {{familytree | | | | | |!| | | D01 | | | |D01=}}
| | | style="padding: 0 5px; font-size: 90%; background: #F5F5F5;" align=center | '''''Preferred Regimen''''' |
| {{familytree | | | | | | E01 | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 14em; padding:1em; color: #FFFFFF;">'''Stabilize the patient'''<br>
| | |- |
| ❑ Assess circulation, secure airway and breathing<br>
| | | style="font-size: 90%; padding: 0 5px; background: #DCDCDC" align=left | ▸ '''''[[Acyclovir]] 400 mg q12h '''''<BR> OR <BR>'''''[[Valacyclovir]] 0.5-2 g PO q12h''''' |
| ❑ Secure IV line<br>
| | |- |
| ❑ Offer [[Oxygen therapy|<span style="color:white;">oxygen</span>]]<br>
| | |} |
| ❑ Cardiac monitor to identify rhythm<br>
| | |} |
| ❑ Monitor [[Blood pressure|<span style="color:white;">blood pressure</span>]] and [[Pulse oximeter|<span style="color:white;">oximetry</span>]]</div>}}
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| {{familytree | | | | | |!| | | | | | | | }}
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| {{familytree | | | | | | F01 | | | | | | | | |F01=<div style="float: left; text-align: center; width: 14em; padding:1em; color: #FFFFFF;">'''Order and EKG immediately'''<br><br>
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| Does the patient has any EKG findings suggestive of an arrhythmia?</div>}}
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| {{familytree | | | |,|-|^|-|.| | | }}
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| {{familytree | | | | G01 | | G02 | | | | |G01={{fontcolor|#F8F8FF|'''Yes'''}}|G02={{fontcolor|#F8F8FF|'''No'''}}}}
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| {{familytree | | | |!| | | |!| | | |}}
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| {{familytree | | | | H01 | | |!| | | | |H01=<div style="float: left; text-align: left; width: 14em; padding:1em;">[[Narrow complex tachycardia#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Narrow complex tachycardia</span>]]<br> [[Wide complex tachycardia#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Wide complex tachycardia</span>]]<br> [[Bradycardia#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Bradycardia</span>]]<br> [[Wolff-Parkinson-White syndrome resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">WPW</span>]]</div>}}
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| {{familytree | | | | | | | | Z02 | | | | | | | | |Z02=<div style="float: left; text-align: left; width: 24em; padding:1em; color: #FFFFFF;">'''Does the patient have any EKG findings suggestive of myocardial ischemia or pericarditis?'''<br>
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| [[STEMI resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">STEMI</span>]]<br>
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| ❑ [[ST elevation|<span style="color:white;">ST elevation</span>]] in at least 2 contiguous leads of 2 mm (0.2 mV) in men or 1.5 mm (0.15 mV) in women in leads V2–V3 and/or of 1 mm (0.1mV) in other contiguous chest leads or the limb leads<br>
| |
| ❑ [[ST depression|<span style="color:white;">ST depression</span>]] in at least two precordial leads V1-V4 (suggestive of [[posterior myocardial infarction|<span style="color:white;">posterior MI</span>]])<br>
| |
| ❑ [[ST depression|<span style="color:white;">ST depression</span>]] in several leads plus [[ST elevation|<span style="color:white;">ST elevation</span>]] in lead aVR (suggestive of occlusion of the [[left main|<span style="color:white;">left main</span>]] or proximal [[LAD|<span style="color:white;">LAD</span>]] artery)<br>
| |
| ❑ New [[LBBB|<span style="color:white;">LBBB</span>]]<br>
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| ----
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| NSTEMI:<br>
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| ❑ [[Non specific ST / T wave changes|<span style="color:white;">Non specific ST / T wave changes</span>]]<br>
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| ❑ Flipped or inverted [[T wave|<span style="color:white;">T waves</span>]]<br>
| |
| ❑ [[Electrocardiogram|<span style="color:white;">ST Depression</span>]]<br>
| |
| ----
| |
| [[Pericarditis resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Pericarditis</span>]]<br>
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| ❑ [[ST segment elevation|<span style="color:white;">ST segment elevation</span>]] in leads I, II, aVL, aVF, and V3-V6<br>
| |
| ❑ [[PR segment depression|<span style="color:white;">PR segment depression</span>]]<br>
| |
| ❑ [[Low QRS voltage|<span style="color:white;">Low QRS voltage</span>]] (in large [[Pericardial effusion|<span style="color:white;">pericardial effusion</span>]] and [[Constrictive pericarditis|<span style="color:white;">constrictive pericarditis</span>]])<br>
| |
| ❑ [[Cardiac tamponade|<span style="color:white;">Cardiac tamponade</span>]]: [[Electrical alternans|<span style="color:white;">electrical alternans</span>]]<br>
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| </div>}}
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| {{familytree | | | | |,|-|-|^|-|-|.| |}}
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| {{familytree | | | | | I01 | | | | I02 | | | |I01={{fontcolor|#F8F8FF|'''Yes'''}}|I02={{fontcolor|#F8F8FF|'''No'''}}}}
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| {{familytree | | |,|-|^|-|.| | | |!| | | |}}
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| {{familytree | | | J01 | | J02 | | J03 | | | | |J01=[[STEMI resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">STEMI</span>]]<br> [[Unstable angina/ NSTEMI resident survival guide#Treatment approach|<span style="color:white;">NSTEMI</span>]]<br>|J02=[[Pericarditis resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Pericarditis</span>]]|J03=<div style="float: left; text-align: left; width: 14em; padding:1em; color: #FFFFFF;">Order a [[Echocardiography|<span style="color:white;">TTE</span>]]</div>}}
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| {{familytree | | | | | | | | | | |!| | | | | |}}
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| {{familytree | | | | | | | | | | | K01 | | |K01=<div style="float: left; text-align: center; width: 18em; padding:1em; color: #FFFFFF;">'''Does the patient have any structural heart disease?'''</div>}}
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| {{familytree | | | | | | | | |,|-|^|-|.| | | |}}
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| {{familytree | | | | | | | | | L01 | | L02 | | |L01={{fontcolor|#F8F8FF|'''Yes'''}}|L02={{fontcolor|#F8F8FF|'''No'''}}}}
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| {{familytree | | | | | | | | |!| | | |!| | | |}}
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| {{familytree | | | | | | | | | M01 | | M02 | | | | |M01=[[Acute heart failure resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Acute heart failure</span>]]<br> [[Aortic stenosis resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">AS</span>]]<br> [[Aortic regurgitarion resident survival guide#FIRE: Focused Initial Rapid Evaluation|<span style="color:white;">Acute AR</span>]]<br>|M02=<div style="float: left; text-align: center; width: 22em; padding:1em; color: #FFFFFF;">'''Does the patient have history of consuming any toxic substance that can explain the palpitations and hemodynamic instability?'''</div>}}
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| {{familytree | | | | | | | | | | |,|-|^|-|.| | | |}}
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| {{familytree | | | | | | | | | | | N01 | | N02 | | | |N01={{fontcolor|#F8F8FF|'''Yes'''}}|N02={{fontcolor|#F8F8FF|'''No'''}}}}
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| {{familytree | | | | | | | | | | |!| | | |!| | | | |}}
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| {{familytree | | | | | | | | | | | O01 | | O02 | | | |O01=<div style="float: left; text-align: left; width: 14em; padding:1em;">[[Alcohol|<span style="color:white;">Alcohol</span>]]<br> [[Cocaine|<span style="color:white;">Cocaine</span>]]<br> [[Heroin|<span style="color:white;">Heroin</span>]]<br> [[Amphetamines|<span style="color:white;">Amphetamines</span>]]</div>|O02=<div style="float: left; text-align: center; width: 14em; padding:1em; color: #FFFFFF;">Look for systemic diseases than can cause palpitations and hemodynamic instability</div>}}
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| {{familytree | | | | | | | | | | | | | | |!| | | | | |}}
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| {{familytree | | | | | | | | | | | | | | | P01 | | | | | |P01=[[Electrolyte disturbance#ACC/AHA/ESC 2006 Guidelines for Management of Patients With Ventricular Arrhythmias and the Prevention of Sudden Cardiac Death (DO NOT EDIT)|<span style="color:white;">Electrolyte disturbances</span>]]<br>[[Hyperthyroidism medical therapy|<span style="color:white;">Hyperthyroidism</span>]]<br>[[Hypoglycemia medical therapy|<span style="color:white;">Hypoglycemia</span>]]<br>[[Hypovolemia#Treatment|<span style="color:white;">Hypovolemia</span>]]<br>}}
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| {{familytree/end}}
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