2. OBJECTIVES
Review the risk factors for atrial fibrillation
Understand the guidelines for anticoagulation
and other pharmacologic drugs where there is
latitude for physician decision making
Be able to determine when patients should be
evaluated for curative ablation versus treatment
with medical therapy
14. Physical Examination
Neurologic Findings
Cerebrum Patient is conscious, coherent, alert, cooperative with intact remote, recent and immediate memory. Oriented to
time, person and place.
Cranial Nerves I
II, III
III, IV, VI
V
VII
VIII
IX, X
XI
XII
Not assessed
Pupils are 2mm wide, equally reactive to direct and consensual lighting
Intact and full extraocular movements. No nystagmus
Intact V1-V3. Can clench both temporalis and masseter muscles. Intact Corneal reflex
Able to demonstrate different facial expressions such as by raising eyebrows, open and closing eyes,
frown, smile, wrinkle forehead, pout, purse lip, and puffing of cheeks.
Able to hear and relay whispered words on both ears.
Uvula in midline. Palate symmetrically rising. Intact Gag reflex
Able to shrug shoulders and rotate the head against resistance.
Tongue at midline moves with ease upon retraction and protrusion, can move from side to side
Cerebellum Able to do finger to nose test. Able to do alternate and supination movement of the hand to thigh.
Sensory
Function
100% on both left and right upper extremities,
Able to distinguish sharp sensation and dull sensation on bilateral lower extremities
15. Physical Examination
Neurologic Findings
Motor Function Muscle strength is 5/5 on lower extremities and 5/5 on upper extremities
Reflexes Biceps = +2
Triceps = +2
Babinski sign: Negative
Meningeal Negative for nuchal rigidity, Negative for Brudzinski sign and Negative for Kernig's sign.
Sensory
100% 100%
100% 100%
Motor
5/5 5/5
5/5 5/5
DTR
++ ++
++ ++
16. Salient Features
DOB
Dyspnea on exertion
Palpitation
CR: 164
RR: 23
Irregular Rate and Rhythm
Diet: Food rich in Oil
and fats / fast food
30yr pack smoker
Heavy alcohol drinker
Both parents: Diabetic
and HTN
18. Differential Diagnosis
Reason for ruling in Reason for ruling out
Hyperthyroidism PALPITATION
TACHYCARDIA
TACHYPNEA
FATIGUE
HEAT INTOLERANCE
SEXUAL DYSFUNCTION
PROTRUDING EYES
19. Differential Diagnosis
Reason for ruling in Reason for ruling out
CHF DOB
PALPITATION
DYSPNEA ON
EXERTION
BIPEDAL EDEMA
CHEST PAIN
COUGH
SOB
22. 22
SUBJECTIVE OBJECTIVE DIAGNOSTIC
(+) DOB
(+)PALPITATION
(+) DYSPNEA ON EXERTION
(-) DOB
(-) Chest pain
(-) Cough
AS Paled Conjuctiva
Irregular Rate and Rhythm
SCE (-) Crackles, (-) rales
Globular abdomen, Non
tender, (-) no direct/indirect
tenderness nor rovsing sign
noted
GNE (-) cyanosis and edema
Vital signs
Bp 130/80
CR 164
RR 23
T 36.6
O2 sat 99 room air
CBC pc, Serum electrolytes
BUN, CREA, ASL, ALT
CBG---143mg/DL
UA
CXR
ECG 12 lead
FBS, lipid profile
Na, k, Mg
Trop I
2decho with DS
23. 23
CBC 7/27/23
HGB 157
HCT 0.47
PLT 154
WBC 7.9
N 0.60
L 0.15
Chemistry 7/27/23
BUN 5.77
CREA 101
Na 137
K 3.9
MG ----
CA ----
Cl ----
ASL 198
ALT 261
U/A
Color yellow
PH TURBID
SG 1.025
PUS 20-30
RBC 3-5
Ketone NEGATIVE
Albumin +1
Sugar Negative
Trop I 133.5
24. 24
- Shows no active
infiltrate.
- Pulmonary vascular
markings are within
normal limits
- Heart enlarged
- The rest of the lungs
are within normal
limits
Chest X-RAY
28. Atrial fibrillation (AF) is the most common sustained
arrhythmia encountered in clinical practice.
It accounts for 1/3 of hospital admissions for cardiac rhythm
disturbances.
AF is a global epidemic and has adverse effects on long term
morbidity and mortality.
There is a significant difference in the incidence of AF in
various populations.
Studies reported a lower incidence of AF in Indian , Asians and
African Americans as compared with White populations.
8 Jun 2020https://doi.org/10.1161/CIRCRESAHA.120.316340Circulation Research. 2020;127:4–20
30. AF triggering factors include
Sympathetic or parasympathetic stimulation.
Bradycardia
PACs - This may be the most common cause Atrial flutter
Supraventricular tachycardias Acute atrial stretch
Catheter ablation of the initiating PACs or SVT can be curative in such patients.
The Pathophysiological Triangle in Atrial Fibrillation
8 Jun 2020https://doi.org/10.1161/CIRCRESAHA.120.316340Circulation Research. 2020;127:4–20
31. RISK
FACTORS
FOR AF
8 Jun 2020https://doi.org/10.1161/CIRCRESAHA.120.316340Circulation Research. 2020;127:4–20
32. RISK
FACTORS
FOR AF
8 Jun 2020https://doi.org/10.1161/CIRCRESAHA.120.316340Circulation Research. 2020;127:4–20
33. RISK
FACTORS
FOR AF
8 Jun 2020https://doi.org/10.1161/CIRCRESAHA.120.316340Circulation Research. 2020;127:4–20
54. 54
SUBJECTIVE OBJECTIVE DIAGNOSTIC
(+) PALPITATION
(-) DOB
(-) ORTHOPNEA
(-) chest pain
(-) Fever
AS Pale Palpebral Conjunctiva
(+) IRREGULARR RATE AND
RHYTHM
SCE (-) Crackles, (-) rales
Globular abdomen, no Epigastric
tenderness, (-) no direct/indirect
tenderness nor rovsing sign noted
GNE (-) cyanosis and edema
Vital signs
Bp 110/70
CR 122
RR 22
T 36.6
O2 sat 97 room air
PT PTT INR
2DECHO WITH DS
SERUM NA K AND MG
ECG 12 LEAD MONITORING Q6
56. 56
CBC 7/30/23
HGB 146
HCT 0.44
PLT 125
WBC 5.8
N 0.67
L 0.28
Chemistry 7/29/23
BUN 7.08
CREA 101
Na 137
K 3.8
MG 0.89
CA ----
Cl ----
ASL 98
ALT ----
U/A
Color yellow
PH TURBID
SG 1.025
PUS 2-4
RBC 3-5
Ketone Negative
Albumin Negative
Sugar Negative
Trop I 133.5---118
58. The left ventricle is dilated with global hypokinesia and evidence systolic dysfunction.
The right ventricle is normal in dimension with adequate wall motion and contractility.
The left atrium is dilated with no evidence of thrombus.
The right atrium is dilated with no evidence of thrombus
The mitral valve leaflets are normal in thickness with no restriction of motion.
The mitral valve annulus is normal.
The tricuspid valve leaflets are normal in thickness with no restriction of motion.
The tricuspid valve annulus is normal.
The aortic valve leaflets are thickened and calcified with slight restriction of motion.
The aortic valve annulus is thickened and calcified.
The pulmonic valve is normal.
The main pulmonary artery is normal.
The pericardium is normal.
DOPPLER:
Mitral Regurgitation, Moderate.
Tricuspid Regurgitation, Mild.
Aortic Regurgitation, Mild.
Pulmonic Regurgitation.
2DECHO with Doppler
EJECTION FRACTION OF : 27
59.
60. 60
PLAN
Diet: LSLF
IVF: HEPLOCK
ECG 12 LEAD MONITORING Q6
VS q 4
I&O Q shift
Medication:
1. ASA 80MG TAB OD
2. CLOPIDOGREL 75MG TAB OD
3. ENOXAPARIN 0.6CC SQ TO COMPLETE 5 DAYS
4. ATORVASTATIN 40MG TAB ODHS
5. LACTULOSE 30CC ODHS
6. OMEPRAZOLE 40MG CAP OD
7. METROPOLOL 25MG TABLET OD
61.
62. 62
DISCHARGE PLANNING
Home Medication:
1. METROPOLOL 25MG TABLET OD
2. CLOPIDOGREL 75MG TABLET OD
3. ATORVASTATIN 40MG ODHS
FOR CONSULTATION TO PHC FOR ASSESSMENT AND FUTHER
WORKUP
FF UP AT IM OPD AFTER 2 WEEKS
67. Take Home Message
1. As Internist properly history and assessment is the key for the early
diagnosis of Atrial fibrillation
2. Properly managing the Atrial fibrillation independently influence
mortality and morbidity
3. OAC’s provide opportunity to minimize growing burden of
potentially preventable thromboembolism (esp AF)
