MDM - Benign Palpitations

[##-year-old male/female] with history and exam consistent with likely benign palpitations.

Initial considerations in this patient included benign etiologies of palpitations including premature ventricular contractions (PVCs), premature atrial contractions (PACs) and premature junctional contractions (PJCs), more significant dysrhythmias including long QT syndrome, Wolff-Parkinson-White syndrome, and Brugada syndrome among others, atrioventricular blocks, acute coronary syndromes, anxiety disorders, thyroid disorders, and palpitations secondary to drugs and medications among others.


Patient presented with report of [## hours/days] of palpitations described as [irregular/rapid and irregular heartbeat/"skipping" heartbeats].  A 12-lead EKG was obtained [with evidence of occasional/frequent PACs/PJCs/PVCs/no evidence of significant dysrhythmia, ectopy or accessory pathways and no evidence of acute ischemia or infarction as noted above].  Labs were obtained in the evaluation of this patient to include [a basic/complete metabolic panel and thyroid studies], which were [noted to be unremarkable/notable for describe abnormality].  Patient [with/without] significant [caffeine/supplement] use [with discussion of decreased use or cessation]. Patient [reported/denied] associated chest pain, and was noted to have no significant risk factors for acute coronary syndrome.

Prior to discharge, we discussed return precautions, specifically for chest pain or other symptoms suggestive of significant cardiac illness, and follow up with primary care doctor for further evaluation and consideration of referral to Cardiology, and the patient demonstrated understanding and agreement with this plan. [A consult was placed for a Holter/event monitor prior to discharge from the ED.]

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.

MDM - Atrial Fibrillation - Rapid Ventricular Rate (RVR)

[##]-year-old [male/female] with complaint of [rapid heart rate/lightheadedness/palpitations] with history and exam consistent with atrial fibrillation with rapid ventricular response (RVR).

Initial consideration in this patient included atrial fibrillation, atrial tachycardia, atrial flutter, sinus tachycardia, paroxysmal supraventricular tachycardia (SVT) from atrioventricular (AV) nodal re-entry 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 atrial fibrillation with evidence of heart rates ranging from [###/140-180] beats per minute consistent with RVR.  Patient reported onset of symptoms [### minutes/hours] prior to presentation in the ED.  Patient [reported/denied] prior similar episodes [with known paroxysmal/underlying atrial fibrillation].  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].  [Cardioversion felt to be contraindicated in patient with over 48 hours of symptoms suggestive of prolonged atrial fibrillation and increased risk for thrombus and potential stroke.  Atrial fibrillation with RVR managed with rate control using Diltiazem/Metoprolol in the ED.  We discussed plan for close outpatient follow up with Cardiology for anticoagulation and delayed cardioversion.]  Procedural sedation considered [inappropriate in patient with evidence of instability warranting emergent synchronized cardioversion at ### Joules/with risks, benefits and alternatives discussed with the patient who provided verbal and written consent prior to sedation as noted above.  Sedation achieved with Etomidate/Ketamine/Propofol without significant complications.].  [Anticoagulation considered in this patient and felt to not be indicated in the setting of clear onset of symptoms in reliable patient within ### hours of presentation to the ED/initiated with heparin/low molecular weight heparin (LMWH) prior to/immediately after cardioversion.]  Cardioversion achieved in the ED with [Amiodarone/Diltiazem/Procainamide/synchronized cardioversion at ### Joules] without significant complications.

Labs were obtained to include [a troponin, CBC, and BMP/other] and were [unremarkable as noted above/notable for abnormality].  We also obtained [a chest x-ray/other] in the evaluation of this patient [which was noted to be unremarkable/abnormality].  Prior to discharge we discussed initiation of anticoagulation, which was felt to [not be indicated/to be indicated based on CHA₂DS₂-VASc score of ### consistent with increased risk for stroke and an ATRIA score consistent with low risk for major bleeding/best be deferred to the patient’s primary care provider on close outpatient follow up].

Prior to discharge, we discussed return precautions, specifically for evidence of recurrent dysrhythmia or worsening cardiac symptoms, treatment [with rate control medication], 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.