6240JorgensenBOxygenationandPerfusionCaseStudy_1_21_24

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Weber State University *

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6240

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Medicine

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Apr 3, 2024

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What diagnosis would you be most likely to give this patient? Explain (Include ICD 10 code) Atrial Fibrillation Unspecified (I48.91) He complains of his heart feeling “fluttery” accompanied by shortness of breath and lightheadedness during and after exercise. He states it only happens sometimes, which wouldn’t be classified as chronic. His heart rate is often too high to count. There is an obvious trigger with exercise but an unspecified cause. His EKG also showed a pattern of atrial fibrillation. How would you treat this patient? Make a treatment plan for the primary diagnosis that you have chosen (include medication, dose, frequency) Plan: - CBC, CMP, TSH, Free T3, Free T4, CK, Troponin, BNP. Labs to evaluate the risk of MI, stroke, pulmonary embolism, and possible underlying causes of A-fib. - Referral to cardiology. - Acute anticoagulation therapy with Apixaban 2.5 mg PO QD. - Metoprolol succinate ER 25mg PO QD. May increase the dose or switch to a different medication if the lowest dose does not provide adequate rate control and episodes continue. - Possibly discontinue lisinopril. Monitor closely for hypotension symptoms. If discontinued. Hank will need a home BP cuff and diary to watch for hypertension if taken off Lisinopril. - Follow-up in one week to assess symptoms and to assess medication safety, efficacy, and side effects. Is there any further testing that you would perform? Why or Why not? In the clinic, I may want to order a chest x-ray to see if any structural lung or heart issues are contributing to the A-fib episodes. A Holter monitor study should also be considered to better capture the episodes over the period of time he is wearing it. A Holter monitor would give us a better idea of patterns, frequency, and length of episodes. Any further testing aside from that mentioned in the treatment plan above must be completed by a referral to a specialist. What referrals/follow up plans would you make at this time?

Referral to cardiology to determine if further testing/procedures are needed. The patient should have a cardiologist as part of his regular care team. Further non-invasive testing with cardiology involvement would be an echocardiogram with the interpretation of results done with a cardiologist, ECG, and a cardiac stress test. If A-fib worsens, collaboration with cardiology should be used for medication adjustments and monitoring. Possible cardioversion or cardiac ablation may be needed if a patient enters into unstable A-fib. What type of education would you provide Hank at this appointment regarding his diagnosis and plan of care? - Discussion of Atrial fibrillation and what it means. Explain about the heart irregular heart pattern and about his increased risk of blood clots and stroke. - Discuss the importance of medication adherence and side-effects/adverse reactions of the medication. Metoprolol can cause bradycardia and hypotension. Regular monitoring of HR and BP should be done while taking this medication. Educate Hank to call with any feelings of severe lightheadedness, fainting, or shortness of breath. Educate Hank not to stop taking this medication abruptly. Apixaban education includes educating Hank about the increased risk of severe bleeding. Educate to call at signs of bruising easily, anemia, blood in urine or stool, heavy nosebleeds, or coughing/vomiting blood. Educate Hank not to stop taking this medication abruptly. - Lifestyle modifications such as continuing to take walks as symptoms allow. Avoid alcohol, as this can make his symptoms worse and interact with his medications. Maintain a healthy diet and continue to manage his DM II appropriately. - Importance of follow-up visits for medications and symptom management. Follow-up visits include both the clinic and cardiology as directed. - Emergency response. Discuss the symptoms of MI, stroke, or bleeding with Hank. Be sure he understands the importance of seeking emergency medical help with any signs of serious conditions or serious adverse reactions to medications. Create an emergency medical response plan with Hank.

References: American College of Cardiology Foundation (2011) Guidelines for the management of patients with atrial fibrillation . American College of Cardiology Foundation . http://content.onlinejacc.org/cgi/content/full/57/11/e101. Kumar, K. (2023). Atrial fibrillation: Overview and management of new-onset atrial fibrillation. UpToDate https://www.uptodate.com/contents/atrial-fibrillation-overview-and- management- of-new-onset-atrial- fibrillation?search=atrial %20fibrillation&source=search_result&selectedTitle=1~15 0&usage_type=default& Kaplan, R. (2023). Control of ventricular rate in patients with atrial fibrillation who do not have heart failure: Pharmacologic therapy. UpToDate. https://www.uptodate.com/contents/control-of-ventricular-rate-in- patients-with- atrial-fibrillation-who-do-not-have-heart-failure- pharmacologic- therapy?search=atrial %20fibrillation&topicRef=1045&source

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6240JorgensenBOxygenationandPerfusionCaseStudy_1_21_24

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