Joseph Martinez who is 68 year old male with " Reason for
encounter: shortness of breath. LATEST CASE
REVIEWED BY EXPERT FEEDBACK LATEST 2024-
2025 .
bp 150/100 HR 136
1. What labs and test would you order?
Labs and Tests
Electrocardiogram (ECG): Urgent to confirm the rhythm (Afib, SVT, etc.).
Chest X-ray (CXR): To assess for any underlying pulmonary causes like heart failure or infection.
Complete Blood Count (CBC): To check for anemia or infection.
Basic Metabolic Panel (BMP): To evaluate electrolytes (especially potassium and magnesium),
kidney function, and glucose.
Cardiac enzymes (Troponin, CK-MB): To rule out myocardial infarction.
Thyroid function tests (TSH, free T4): Hyperthyroidism can precipitate arrhythmias.
B-type natriuretic peptide (BNP): To assess for heart failure.
D-dimer (if pulmonary embolism is suspected).
2
3 Medications? IVP Metoprolol, Cardizem drip or Amio drip
Start Heparin drip or PO eliquis
Medications and Treatment Options
Acute Management:
Rate Control:
IV Metoprolol (Beta-blocker): Helps to control the heart rate in atrial fibrillation or other
tachyarrhythmias.
Dose: 2.5-5 mg IV push over 2 minutes, repeat as needed.
IV Cardizem (Diltiazem) (Calcium channel blocker): Used for rate control in Afib with RVR,
especially in patients where beta-blockers are contraindicated.
Bolus: 0.25 mg/kg IV over 2 minutes, then an infusion at 5-15 mg/hour.
Amiodarone drip: Can be used if there is concern for rhythm control or if the patient is unstable or
refractory to other treatments.
, Load: 150 mg IV over 10 minutes, then 1 mg/min for 6 hours, followed by 0.5 mg/min.
Anticoagulation:
Heparin drip: Initiate if there is concern for a thromboembolic event due to atrial fibrillation,
especially if this is a new onset. A bolus followed by a continuous infusion can be started with
weight-based dosing and titrated based on PTT levels.
PO Eliquis (Apixaban): This may be considered if the patient is stable, without a need for urgent
reversal, and has no contraindications for long-term anticoagulation (used for long-term stroke
prevention in Afib).
Dose: Typically 5 mg twice daily (adjust based on renal function and patient profile).
Additional Considerations
Electrolyte correction (potassium and magnesium): Ensure these are within normal ranges to
prevent further arrhythmias.
Oxygen therapy: If the patient is hypoxic or in respiratory distress.
Monitor closely: Continuous cardiac monitoring and repeat ECG to assess response to treatment.
The decision to use a heparin drip vs. PO Eliquis will depend on the urgency, risk factors for stroke,
and whether cardioversion is being planned. Immediate anticoagulation (heparin drip) is often
preferred in the acute setting when stroke risk is high.
Questions – 100 %
How can I help you today?
2 Are there any other symptoms or concerns we should discuss?
3 When did your difficulty breathing start?
4 Does anything make your difficulty breathing better or worse?
5 Are you short of breath when lying down?
6 Are you short of breath at rest?
7 Do you sleep with pillows to help you breathe?
8 Do you have any pain or symptoms associated with your difficulty breathing?
9 How severe is your difficulty breathing?
10 Do you wheeze?
11 Do you become short of breath with exertion?
12 Do you awaken at night short of breath?
13 Does anyone in your family have difficulty breathing?
14 Do you feel faint or like you might faint?
15 Do you have a problem with fatigue/tiredness?
16 Have you been having fevers?
17 Have you noticed any swelling in any part of your body?
18 Do you have a problem with generalized weakness?
19 Do you have a cough?
20 Do you have unusual heartbeats?
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