Physician's Assistant

Meeting (283 days ago 14:17)

Meeting Fri 27 June 2025 14:17

Last Modified: 283 days ago

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Clerking (283 days ago 14:21)

Clerking Fri 27 June 2025 14:21

Last Modified: 283 days ago

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Medical ST4 Miller Clerking

Presenting Complaint:
Atrial flutter with poor rate control

History of Presenting Complaint:
Patient presented with 3 weeks of palpitations and fluttering sensation in May 2025. Initially diagnosed with atrial flutter on 30th May 2025 and commenced on Apixaban and Bisoprolol. Despite up-titration of Bisoprolol from 2.5mg to 5mg daily, heart rate remains elevated at 144-147 bpm. Patient reports improvement in symptoms since starting treatment, with reduced palpitations and no racing sensation when lying down. Recently treated for chest infection with Doxycycline with good response. Reports ankle swelling and fluid retention since Bisoprolol increase.

Past Medical History:
• Atrial flutter - May 2025
• Sarcoidosis - 2013
• Central hypertension - 2010

Medication History:
• Apixaban 5mg PO BD
• Bisoprolol 5mg PO OD
• Doxycycline (recent course for chest infection)

Allergic History:
Unknown

Social History:
Works as factory engineer on night shifts. Regularly walks 10,000+ steps per shift. Lives independently. Rare alcohol consumption. Stopped drinking coffee, drinks tea regularly. Non-smoker.

On Examination:
Bilateral ankle oedema present. Chest examination suggests resolving chest infection.

Investigations:
Urea 8.4, Creatinine 78 (baseline 73), NT-proBNP 1,274, INR 1.0, FBC normal, Blood gas normal except glucose 6.1. CXR 31/05/2025: Isolated lymphadenopathy, no focal infective signs. ECG: Atrial flutter, rate 144 bpm.

Impression:
Atrial flutter with inadequate rate control despite optimal beta-blockade. Developing heart failure secondary to tachycardia.

Plan:
1. CXR [_]
2. Up-titrate beta blockade as tolerated by BP [_]
3. Add Ca, Mg, TSH +/- replace [_]
4. Discussed with cardiology SpR Hawley [_]
   - Admit for rate control [_]
   - Up-titrate with Bisoprolol 2.5mg stat [_]
   - If rate not controlled, give further Bisoprolol 2.5mg stat [_]
   - If rate remains uncontrolled following above, load with Digoxin IV 500mcg + 500mcg, then 125mcg daily from tomorrow [_]
   - Cardiology review in the morning [_]

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Custom (283 days ago 14:50)

Custom Fri 27 June 2025 14:50

Last Modified: 283 days ago

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PTWR
Dr Tuffnell-Barrett

CLINICAL PRESENTATION:
Patient presents with atrial flutter identified on ECG, symptomatic for over one month. Initially noticed palpitations over a 3-week period with increasing frequency, particularly when lying down, which prompted GP visit. Since starting bisoprolol, patient reports significant improvement in flutter sensation, though occasional episodes persist.

- Ankle swelling (developed after increasing bisoprolol to 5mg)
- Intermittent palpitations
- Heart rate 146 bpm at recent GP check despite feeling well subjectively

- Ex-smoker (15 years)
- Minimal alcohol consumption
- Avoids caffeine, occasional tea
- Night shift worker
- No family history of cardiac arrhythmias

ASSESSMENT:
Atrial flutter with evidence of heart failure secondary to tachycardia. Patient experiencing medication-related side effects (ankle swelling from beta-blocker). Background sarcoidosis stable.

MANAGEMENT PLAN:
1. Hospital admission for cardioversion and electrophysiology assessment
2. Review current medication regime given low blood pressure and side effects
3. Consider amiodarone vs alternative rate control
4. Electrophysiology mapping with view to potential ablation
5. Blood pressure monitoring during admission

The patient is agreeable to hospital admission for definitive management.

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Sdec (283 days ago 14:03)

Sdec Fri 27 June 2025 14:03

Last Modified: 283 days ago

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Presenting Complaint:
Atrial flutter with persistent tachycardia despite medical therapy

Past Medical History
• Atrial flutter (May 2025)
• Sarcoidosis (2013)
• Hypertension (2010)

Diagnosis:
Atrial flutter with inadequate rate control, concurrent chest infection

I had the pleasure of meeting Scott Powell in Same Day Emergency Care today.

Mr Powell is a 35-year-old factory engineer who initially presented on 30th May 2025 with a 3-week history of chest fluttering. He was diagnosed with atrial flutter and commenced on Apixaban 5mg BD and Bisoprolol initially 2.5mg OD. On review on 6th June, his heart rate remained elevated at 144 bpm despite treatment, so his Bisoprolol was increased to 5mg OD. His BP at that time was 105/70 mmHg.

Today he presents for routine follow-up. He reports significant improvement in his fluttering symptoms and no longer experiences the racing sensation when lying down. However, he has developed bilateral ankle and foot oedema over the past 10-14 days since the Bisoprolol dose increase. He works night shifts as a factory engineer, easily achieving 10,000+ steps per shift. He has recently completed a course of Doxycycline for a chest infection which has largely resolved.

On examination today, his heart rate remains elevated at 146 bpm with hypotension (BP 90/60 mmHg). Oxygen saturations are 98% and temperature 36.9°C. He appears well, not tachypnoeic, and speaks in full sentences. There is bilateral pedal and ankle oedema present. Chest examination reveals left lower zone crepitations. No chest pain or tightness at rest, though he reports some chest tightness on walking uphill which predated his atrial flutter diagnosis.

Investigations:
Urea 8.4, Creatinine 78 (baseline 73)
NT-proBNP 1,274
INR 1.0
FBC normal
Blood gas normal apart from glucose 6.1
Chest X-ray 31/05/2025: Hilar lymphadenopathy but no signs of focal infection
ECG: Atrial flutter with ventricular rate 144 bpm
CXR 27/06/2025: Clear lung fields

Plan:
1. CXR
2. Up-titrate beta blockade as tolerated by BP
3. Add Ca, Mg, TSH +/- replace
4. Discussed with cardiology SpR Hawley
- Admit for rate control
- Uptirate with Bisoprolol 2.5mg stat
- If rate not controlled, give further Bisoprolol 2.5mg stat
- If rate remains uncontrolled following above, load with Digoxin IV 500mcg + 500mcg, then 125mcg daily from tomorrow
- Cardiology review in the morning

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Meeting Fri 27 June 2025 14:17

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Clerking Fri 27 June 2025 14:21

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Custom Fri 27 June 2025 14:50

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Sdec Fri 27 June 2025 14:03

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