MDM - Supraventricular Tachycardia (SVT)

[##]-year-old [male/female] with complaint of [rapid heart rate/lightheadedness/palpitations] with history and exam consistent with supraventricular tachycardia (SVT).

Initial consideration in this patient included paroxysmal supraventricular tachycardia (SVT) from atrioventricular (AV) nodal re-entry tachycardia, atrial fibrillation, atrial tachycardia, atrial flutter, sinus tachycardia, multifocal atrial tachycardia, ventricular tachycardia, acute coronary syndrome (ACS), and various drug and medication effects including caffeine, alcohol, cocaine and other drugs of abuse, and other medications including digoxin among others.

Patient presented with complaint of [lightheadedness/palpitations/chest pain] with initial EKG noted to show SVT with heart rates ranging from [###/140-180] beats per minute.  Patient reported onset of symptoms [### minutes/hours] prior to presentation in the ED.  Patient [reported/denied] prior similar episodes [with known paroxysmal SVT].  Patient placed on cardiac monitors with pacing/defibrillation pads placed on the patient upon arrival in the ED.  Patient felt to be [stable/unstable] based on [absence of chest pain, hypotension, dyspnea, or altered mental status/presence of ischemic chest pain/systolic blood pressure less than 90 mmHg/acute pulmonary edema/altered mental status]. 

[Synchronized cardioversion/Modified positional vagal maneuver/Rapid intravenous infusion of adenosine] felt to be appropriate initial management in [stable/unstable] patient.  Initial attempt at cardioversion with [synchronized cardioversion/modified vagal maneuver/adenosine 6 mg] noted to be [successful/unsuccessful with additional attempt with adenosine 6/12 mg/diltiazem/synchronized cardioversion].  Cardioversion to [normal sinus rhythm/sinus tachycardia] achieved in the ED with [vagal maneuver/adenosine/diltiazem/synchronized cardioversion] as noted above without significant complications.

We considered possible precipitants of SVT to include drugs including caffeine and other stimulants, alcohol, electrolyte abnormalities, and thyroid disease amongst others.  Patient noted to have [no history of stimulant use/reported caffeine/dietary supplement/illicit drug] as a likely precipitant of SVT.  Patient felt to have [no evidence of thyroid disease/a normal TSH] making underlying thyroid disease unlikely.  Labs obtained to include a metabolic panel, which [showed no evidence of significant electrolyte abnormalities/was notable for electrolyte abnormality].  Prior to discharge we discussed increased fluid intake and avoidance of stimulants [as well as supplementation of appropriate electrolyte/follow up for thyroid disease].

Prior to discharge, we discussed return precautions, specifically for evidence of recurrent SVT or cardiac symptoms, treatment with increased fluid intake [and electrolyte supplement], and close follow up with primary care provider and Cardiology within the next [2-3 days/week] for further evaluation and management, and the patient demonstrated understanding and agreement.