Transcription - 20260317T 11-25.mp3

So next patient is ankraznopolsky 64 year old lady medications list no current repeat medication problems list central tremor paroxysmal atrial fibrillation diagnosed january 2025 migraine 2023 so investigations crp of 1 iron on 0.9 renal function normal troponin normal thyroid function normal bone profile normal lfts urea ast normal phosphate normal magnesium normal full blood count white cells 11.5 with neutrals 10.68 otherwise venous blood gas ph 7.38 lactate 0.9 chest x-ray clear lung fields bilaterally some upper lobe diversion compared to previous he made previous presentations with paroxysmal af in january 2025 where she spontaneously cardioverted with iv fluids and most recently saw the cardiac nurse in december 2025 when she's in normal rhythm she runs with her heart rate in the forties and saying she's not having any medication or pill in the pocket medicine and she's being referred on to electrophysiology for assessment of ablation most recent echocardiogram july 2025 good lv systolic function 66% normal wall thickness mild tr trivial pulmonary regurgitation sinus bradycardia heart rate circa 50 good left ventricular systolic function mild mr / tr has been treated with 3 0.5 followed by 2.5 mg of bisoprolol observations heart rate between a 111 and a 150 beats per minute up to a 167 at 1. With maintained blood pressure throughout dipping to a 115 over 87 at the lowest sats 99% on air a febrile temperature of 36.5 and respiratory rate 18 breaths per minute hello hi this is krasnikowski hi I'm rob hi I'm 1 of the medical groups we are I'm calling you how are you good I'm to it in fact it's cool to know other than the whole fast heart rate thing how do feel you I've been vomiting you've vomited yeah has that all started at all are you conscious of your time it's a lot of bad news I felt a little I don't know if I'm 6 but I've got blown away after about 2 hours mhmm and you've had this before so you know what it feels like yeah this was worse yeah the time before I stayed at home for 2 hours and then I did nhs 1 on my left side and I didn't really feel very well like it wasn't going well this time I half an hour after I was sent to hospital I really don't feel well at all yep and it seems more intractable this time last time I just had flu yeah it seems like it that was like a year ago more than a year ago yeah 14 months yeah and I had an episode a year before that which is not proven as af because I stayed at home and I came in later sounds stupid but I felt better it was a friday night it was post covid times and I thought I can't face amy I'm just gonna lie in my bed and it just goes away yeah and it and woke up in the morning and by until I went in I was in sinus rhythm mhmm but when I went in january 25 they said it sounded very similar right the first time when I got 2 hours later I sort of passed out on the bed and stuff they thought it was probably the same and I understand you've seen a cardiac nurse once or twice I've seen a cardiac nurse once and had a phone call from another 1 I'm not seeing a consultant yeah and you're being referred on to an electrophysiologist aren't you to talk about an ablation of your heart yeah in actual fact haven't talked to a general cardiologist I've been offered statins and things and I wasn't sure whether to take them mhmm and we wanted to travel my husband's 10 years older and mike was on hold for a year mhmm and I actually asked for a referral to doctor griffin privately yesterday okay and then this is all things off maybe I don't know the ablation it felt a bit dramatic for what I've had before but with this this is more scary and obviously medication is difficult because you go quite slow yeah normally yeah and so slow me down anymore yeah you're not back in so no I guess I really I really feel quite sad this time more so young before so yeah but you're gonna take place well looked after you are going fast yeah how would you 200 when I went to the loo just now really wow yeah yeah recently have you been feeling well other than the vomiting that you had in the early hours of the morning have you been feeling well in yourself do have any fevers or no I mean I I get a lot of aches and pains I've had know sort of more stuff like that than usual but other than that no fevers or upper respiratory my my husband had a a sort of sore throat and a cold about a week ago okay so I now been fighting what had right do you feel like you've got that or not no no certainly your markers of infection and inflammation in your blood are not very high oh okay yeah 1 of the markers is high but that can go up when you're ill for whatever reason okay so it it could be related a mild infection but it also could not be no I haven't felt fine yeah yeah and you had an echocardiogram a while ago back in july yeah of last year which was fine wasn't it and are you confident that this is the only time you've gone into this fast irregular heart rhythm I quite often feel as though my heart is beating in its place pattern do you for a little while and and then I just it calms down and how long is it a little while maybe 10 minutes okay and I saw that when I had the 5 day timer I found the report from that quite confusing because it said I was having some episodes of af some of fvts and other fast rhythms but nothing diagnostic and I couldn't quite make out the significance of that I had this kind of okay which think sounds that weird or it's like I'm looking at phone right over okay is that is that what this is just well obviously you know you get a bit worried when it's particular and that doesn't help yeah of course april 24 is that what we're talking about no no I think it would be '25 okay may july 25 they may not have it hang on I'll no have a letter from doctor graham but not the actual report itself yeah for some occasions atrial fibrillation there seems to be some other signs of a more regular rhythm fine and I had an attitude joke yeah really and I said she just had the the software limitations man they couldn't have been helpful to oh really yeah because they would have worse right okay supraventricular tachycardia is an umbrella term that describes any fast heart rate coming from or up the ventricles af is a supraventricular tachycardia by definition it's yeah without seeing the report because I just got her letter haven't got the report I think she did manage to locate it it will be in your paper notes they will be on the way at least it is not a good friday hopefully then everything will be good imagine that would be a few things happen first I call it day weekend but we need more coffee to meet people makes perfect sense on the lead I for when it going to have a quick look at you do you mind if you answer thanks very much my question is about what we should do to manage this we have had a clinic at sorry done anything 2 now 2 lots yes 2.5 and 2.5 at the subprolol and nothing's really changed so should we be pursuing controlling your rate or should we be pursuing trying to put you back into a normal rhythm if you're confident that you've gone that this what's happened and you're confident that you feel like you're normal and you feel like you're in atrial fibrillation we could consider doing a couple of things to try and get you back into a normal rhythm we could shock you we could just make you quite sleepy and shock you here or we could give you a drip of a medicine which you have a shot of here and you have a drip of over 24 hours to put your heart back into an awl in order to do that you'd need to go either way you'd need to go from here to our coronary care unit to see a cardiologist so I think I should go and check to the cardiologist if they're just flushed away see whether they live here happen to have you and be aware that they would be happy to have you having had a drift some medicine to put your heart rate to a normal rhythm and they may suggest having a look with an echo probe for that just to make sure you haven't got a clot in 1 part of the heart the risk of doing those things putting you into a normal rhythm is that if there is a flop there it can be thrown off into your brain and it can cause a stroke which is why we want to avoid that hurdle across we obviously put people who are working up to an ablation on blood thinning medicines to make sure that there's nothing wrong but we usually give those blood thinning medicines for 6 weeks before we ablate the heart in order to put the rhythm back to normal haven't obviously got like 6 weeks worth of anticoagulation so you need to think about the risk benefits of that but you are going fast at the moment and your heart doesn't look happy going that fast on that tracing to me so I would suggest trying to that's do something about what you're saying on the ecg as well as this exactly the speed and also yeah the pattern of it makes it look like the heart is unhappy going that fast many very few people's hearts will be very happy it's going going on since 06:00 now yes may not be that long to you if that makes sense no no it's horrible to have the symptoms for that long so yeah and and then thinking back so 06:00 had started after you vomited I didn't vomit then I thought I felt sick I vomited here sorry between the first and second no that's fine so you felt nauseated at home yeah but you weren't sick you felt like you were going into the funny heart rhythm around 06:00 sounds good you were sick then yeah alright yeah okay and then thinking back before 06:00 in the morning when you had this funny heart rate when's the time you had the funny heart rate before that I have not had a serious episode since september I believe here it calmed down but I felt rubbish all day but you have had other little 10 minute episodes little 10 minute episodes when's the last time you had the 10 minute episode before that it's a daily occurrence yeah quite common yeah and I don't really register it yeah fine understood but you do have the sensation as long as that happens I have a sort of sense of unease mhmm and I'm not quite sure whether it you know obviously stress doesn't help with it I think I'm passively up and going to more breathlessness than I used to be yeah I've always had a murmur of I think it's my tricuspid valve yeah so from childhood I'd get better breath running and stuff or going up hills if I walk mhmm but like when I'm just doing short of mild housework and stuff or something I'm puffing a bit in a way I wouldn't have done yeah couple years ago yeah then thinking back obviously further in time you said you had these long standing symptoms of worsening shortness of breath what's your exercise tolerance like over the last few weeks I mean I I don't know how many I live in livermore yeah I walked to hopkins on the other week with a friend I was quite out of breath talking it's quite up uphill coming back yeah of course she was out of breath too fine so not too bad so you're usually pretty unlimited by by then going on yeah I you know I often stop and sit down and have an adrenaline and wait 5 minutes and then but is your does your friend wanna do the same thing or is it she was happy to okay yeah she's my age and she was happy to so nothing but didn't want me to feel over yeah of course is caffeine and alcohol are those things for you or not I don't have alcohol taking for migraines it makes it worse so I haven't had alcohol for about 2 years caffeine I have we have 2 cups of tea with caffeine in the morning and a coffee and the rest of the day I had decaf mhmm today I've not had any caffeine we had a tea this morning but I said to adam you better get me decaf because you'll see quite lovely wrecking yeah fun yeah and when's the last time you had someone to eat and drink just today I had a cup of tea after I came and I've not had anything to eat okay I don't feel I'm on top yeah that's good fine just if we may if we're shocked you'd then and then you'd want me to start a bit a bit before which sounds good I could you sit forward I'll listen to your back thank you so would this be a bit like being defibrillated say what would this be like being defibrillated yeah same sort of voltage or or is it less or we we usually use the same voltage same amount of energy certainly good breaths for me yeah perfect and again thank you that's great that's great I have got a 2 level a little bit of fluid on the lungs I think just so you make this with your heartbending box any swelling dear not for you no cool let me go take the interview and chat to the cardiologist then and I'll come back with some options about what we would do does that sound okay have I forgotten anything any questions no haven't forgotten anything good very short sorry I don't mean to scare you no you're not but I think we've got lots of ways we can sort it out I just need to get it sorted for you instead of sitting you on some fluids for 2 days and deciding that places and exactly works so good yeah so nice well it's fine you're the right place you're looking after we'll get a bit I'll see you a bit alright is that working should we be controlling her rhythm she's inflamed she's gonna look fast she's got a cataract she's got a cataract cataract ct and is an rda so on examination heart sounds fast heart rate a 180 to 200 beats per minute with evidence of ischemia on 12 with widespread st depression saturation is 96% on air respiratory rate 27 with blood pressure a 140 over 78 evidence of some mild peripheral edema and bibasal fine inspiratory crepitations abdomen soft and nontender no known drug allergies impression paroxysmal fast atrial fibrillation with evidence of cardiac failure not responding to beta blockade <\n> High risk beta blockade given previous brad dcardia plan discuss with cardiology consultant on call doctor side review dcg discuss patient agrees with plan for rhythm control with dc cardioversion suggests dose of treatment dose low molecular heparin prior to cardioversion in addition to this it can come to cardio ward following if required large bore iv access if amiodarone required anesthetic review to discuss sedation for to facilitate dc cardioversion consented for dc cardioversion on a written consent form and discussed risks including 1 less than 1% risk of stroke will need ongoing anticoagulation following for paroxysmal atrial fibrillation until ablation as chadsvet score will be high next year update all teed up for anticoag for cardioversion anesthetic team kindly reviewed on administration of heparin patient spontaneously cardioverted with rate 80 and sinus rhythm on ecg plan for now for continued observation and cardiac monitoring slow iv fluids needs anticoagulation on discharge suggest starting apixaban tomorrow due to administration of truvadose lam and I could get heparin today

Medical ST5 Miller Clerking
Date: 26/03/2017 12:53

Presenting Complaint:
Paroxysmal fast atrial fibrillation

History of Presenting Complaint:
A 64-year-old lady with known paroxysmal AF presented with palpitations and vomiting. Symptoms began at approximately 06:00, when she felt nauseated and noticed onset of a fast, irregular heart rhythm. She vomited on arrival to hospital. She described the episode as worse than previous presentations and felt unwell throughout.

She has had at least two prior documented episodes of paroxysmal AF. The most recent was in January 2025, during which she spontaneously cardioverted with IV fluids. Approximately 12 months prior to that, she had a further episode which was not confirmed as AF as she remained at home and was in sinus rhythm by the time she attended hospital. She also reports frequent short episodes of palpitations lasting approximately 10 minutes, which she describes as a near daily occurrence, often accompanied by a sense of unease. She had a 5-day cardiac monitor (May/July 2025) which reportedly showed some episodes of AF and other fast rhythms but nothing diagnostically conclusive.

She was most recently reviewed by the cardiac nurse in December 2025, at which time she was in sinus rhythm with a resting heart rate in the forties. She is not on any rate-limiting or pill-in-pocket antiarrhythmic medication. She has been referred to electrophysiology for consideration of catheter ablation.

She reports worsening exertional dyspnoea over the past couple of years, noting breathlessness on mild exertion such as housework, which represents a decline from her previous baseline. She has a longstanding history of a tricuspid valve murmur since childhood with associated mild exertional dyspnoea. She denies fevers or coryzal symptoms, though her husband had a sore throat and cold approximately one week prior. She has not had alcohol for approximately two years (abstains due to migraine). She takes 2-3 caffeinated drinks in the morning and decaffeinated beverages thereafter. She had not eaten since admission and had only a cup of tea.

During the consultation, she reported that her heart rate reached approximately 180-200 bpm when she went to the toilet. Rate control was attempted with two doses of bisoprolol 2.5mg without significant effect. Given the haemodynamic compromise, ongoing ischaemic changes on ECG, and failure to respond to beta-blockade, rhythm control via DC cardioversion was discussed and agreed upon.

Subsequently, following administration of treatment-dose low molecular weight heparin, the patient spontaneously cardioverted to sinus rhythm with a heart rate of 80 bpm.

Past Medical History:
• Essential tremor
• Paroxysmal atrial fibrillation - diagnosed January 2025
• Migraine - 2023
• Longstanding tricuspid valve murmur (since childhood)

Drug History:
No current repeat medications.

Allergy History:
• NKDA

Social History:
Alcohol: None for approximately 2 years (avoids due to migraine).
Caffeine: 2-3 caffeinated drinks in the morning, decaffeinated thereafter.

On Examination:
Observations (on arrival): HR 111-167 bpm; BP 115/87 mmHg (lowest recorded); Temp 36.5°C (afebrile); RR 18 breaths/minute; O2 sats 99% on air.
Observations (at time of examination): HR 180-200 bpm; BP 140/78 mmHg; RR 27 breaths/minute; O2 sats 96% on air.
• Cardiovascular: Heart sounds fast. Heart rate 180-200 bpm. 12-lead ECG with widespread ST depression in keeping with ischaemia. Mild peripheral oedema noted bilaterally.
• Respiratory: Bibasal fine inspiratory crepitations consistent with mild pulmonary oedema.
• Abdomen: Soft and non-tender.

Investigations:
• CRP: 1
• Iron: 0.9
• Renal function: Normal
• Troponin: Normal
• Thyroid function: Normal
• Bone profile: Normal
• LFTs (urea, AST, phosphate, magnesium): Normal
• WBC: 11.5 (neutrophils 10.68)
• Venous blood gas - pH: 7.38, lactate: 0.9
• Chest X-ray: Clear lung fields bilaterally with some upper lobe diversion compared to previous imaging
• Echocardiogram (July 2025): Good LV systolic function (EF 66%), normal wall thickness, mild MR, mild TR, trivial pulmonary regurgitation
• 5-day cardiac monitor (May/July 2025): Occasional episodes of AF and other fast rhythms; no definitive diagnostic conclusion
• 12-lead ECG (today): Fast AF with widespread ST depression; sinus bradycardia with HR approximately 50 bpm on prior tracing

Impression:
Paroxysmal fast atrial fibrillation with evidence of acute cardiac decompensation (pulmonary oedema, peripheral oedema, ischaemic ECG changes), not responding to beta-blockade.
Note: High-risk beta-blockade given prior history of bradycardia.

Management Plan:
1. Discussed with on-call cardiology consultant - reviewed and agreed management plan.
2. Rhythm control strategy agreed with patient following discussion of risks and benefits, including a less than 1% risk of stroke associated with DC cardioversion.
3. Written consent obtained for DC cardioversion.
4. Treatment-dose low molecular weight heparin administered prior to planned cardioversion.
5. Anaesthetic team reviewed to facilitate sedation for DC cardioversion.
6. Following administration of heparin, patient spontaneously cardioverted to sinus rhythm (HR 80 bpm on ECG).
7. Continue cardiac monitoring and observation on cardiology ward.
8. Slow IV fluids.
9. Large-bore IV access to remain in situ in case amiodarone is required.
10. Anticoagulation: Apixaban to be commenced tomorrow given treatment-dose LMWH administered today. Ongoing anticoagulation required post-discharge for paroxysmal AF (CHA2DS2-VASc score elevated) until ablation is completed.
11. Ongoing cardiology follow-up; electrophysiology referral for catheter ablation already in progress.
12. Patient to be admitted to cardiology ward for continued monitoring.

Summary

Investigations

Plans