AFib
Age: years old
Gender:
HISTORY:
Presents with
Current symptoms:
, , , ,
Worsening factors:
Alleviating factors or treatments tried: ,
Contributing factors:
no history of: , , , , , , ,
no use of: ,
EXAM:
General appearance: ,
Vital signs: , BP , HR , RR , SpO2 %, Temp °
Neck: , , , c-spine
Heart: , ,
Lungs: , ,
Extremities: , , cap refill sec, pulses , ,
ASSESSMENT:
DDx: atrial fibrillation, atrial flutter, supraventricular tachycardia, sinus tachycardia, ventricular tachycardia, premature atrial contractions, premature ventricular contractions, thyroid disorders, pulmonary embolism, pneumonia, chronic obstructive pulmonary disease, acute coronary syndrome, myocarditis, pericarditis, cardiomyopathy, electrolyte imbalances, alcohol intoxication, stimulants abuse
PLAN:
Investigations:
- ECG
- Blood work: , , , , ,
- Chest X-ray
- Echocardiogram
- Holter monitor
- Stress test
Treatments:
-
-
-
- Electrical cardioversion
Further care:
- Referral to cardiologist
- Follow-up in
- Return if symptoms worsen or if new symptoms develop such as chest pain, shortness of breath, or fainting
- Referral to ER if severe chest pain, severe shortness of breath, or fainting occurs
HISTORY: EXAM: ASSESSMENT: PLAN: