Atrial Fibrillation (AF) With A Rapid Ventricular Response
September 17th, 2008Dr. D.S. Merchant is a Gold Medalist in (Anatomy & Histology), Fellow Nephrology. For more information on Atrial Fibrillation or visit Explore Article is a popular website that offers information on liver disease and liver treatment.
Atrial Fibrillation (AF) With A Rapid Ventricular Response
Case 2
• A previously healthy 22-year-old woman presents to the emergency department (ED) with acute shortness of breath. Her shortness of breath became worse with exertion and was associated with pleuritic chest pain for 2 days. She has had a fever, nonproductive cough, nausea, vomiting, and arthralgia.
On presentation, she is febrile with a temperature of 101.5°F (38.6°C), a blood pressure of 88/54 mm Hg, a pulse of 104 bpm, a respiratory rate of 28 breaths/min, and an oxygen saturation of 88% while breathing room air. Her oxygen saturation improved to 92% with supplemental oxygen given at 2 L/min. She is in moderate respiratory distress; however, she can speak in full sentences. Her physical examination reveals absent breath sounds throughout the right thorax, with decreased breath sounds halfway up the left thorax. Other findings include egophony, decreased fremitus, and dullness to percussion on the right thorax. She has no jugular venous distention, edema on her lower extremity, or rash.
What is the diagnosis?
Diagnosis:
Case 3:
• A 66-year-old man presents to the Emergency Department (ED) with chest pain and shortness of breath that started several hours ago as he was cleaning his Civic VTI. His chest pain is dull in quality and radiates to his neck and arms, and when asked to rate the severity of the pain, he indicates a 5 in a range from 1 to 10 (with 10 being the worst). The chest pain is not associated with diaphoresis, nausea, or vomiting. The patient also had exertional weakness for 4 days. He denies having dizziness, lightheadedness, or loss of consciousness.
• The patient underwent a 3-vessel coronary artery bypass 8 years ago. Since then, he has had stable angina that occurs approximately once a month. His medical history is also clinically significant for hyperlipidemia, hypertension, and poorly controlled insulin-dependent diabetes mellitus. His medication regimen includes hydrochlorothiazide, insulin, isosorbide dinitrate, simvastatin, aspirin, and sublingual nitroglycerin as needed. The patient smokes 2 packs of cigarettes per day. The review of systems yields unremarkable findings.
• The patient is afebrile but appears uncomfortable. The cardiovascular examination reveals bradycardia. His heart rate is 39 bpm and regular, his blood pressure is 130/53 mm Hg, and his respiratory rate is 18 breaths per minute. His first and second heart sounds are normal. No murmur or gallop is present. Except for evidence of his previous surgery, his other physical findings are normal.
• The patient’s laboratory results are normal except for mildly elevated troponin I levels. An ECG is obtained (see Image 1).
ECG findings:
• The characteristic ECG findings of third-degree AV block are atrial impulses that consistently fail to reach the ventricles, atrial and ventricular rhythms that are independent of each other, variable P-R intervals, consistent P-P and R-R intervals, and atrial rates faster than ventricular rates.
• Complete heart block occurring at the AV node is typically associated with slow but stable junctional escape rhythms and normal QRS complexes. If the AV block is below the bundle of His, subjunctional escape rhythms further slow heart rates and widen QRS complexes.
Management:
• The therapy for complete heart block begins with correction of the reversible causes of the dysrhythmia, such as treating myocardial ischemia and discontinuing drugs that suppress the conduction of cardiac action potential. In urgent situations, intravenous atropine may be used to reverse decreases in AV nodal conduction. If the patient’s condition responds to atropine, the conduction dysfunction is at the level of the AV node. The conduction system distal to the AV node is relatively unresponsive to atropine.
• In patients with a wide-complex escape rhythm and suspected acute MI, atropine should be withheld or used only with extreme caution, as it may result in unopposed sympathetic stimulation. The subsequent risk of increased ventricular irritability and potential arrhythmia is likely to be greater than the improbable benefit on the conducting system distal to the AV node. When this occurs, or when the complete heart block is unresponsive to atropine, temporary and/or permanent placement of a pacemaker may be necessary
Case 4:
• A 32-year-old woman presents to the emergency department with several flesh-colored papules on her face, trunk, and upper extremities. She noticed the lesions at approximately 10 years of age. However, over the past 5 years, the lesions have increased in number and become uncomfortable. She primarily complains of irritation from the lesions along her bra line. She previously underwent excision of other similar skin lesions 5 years ago, but these have since recurred. She denies having discharge, pain, trauma, contact with individuals with atypical skin lesions or rashes, travel out of the country, unusual exposure to animals, or a history of sexually transmitted disease.
The patient"s medical and surgical history includes environmental allergies, frequent episodes of bronchitis, and the aforementioned excisions. She takes cetirizine HCl (Zyrtec) and fluticasone propionate (Flonase) for allergies and has no known drug allergies. Her family history is significant for coronary artery disease, hypertension, diabetes mellitus, and glaucoma. She does not smoke and drinks alcohol on occasion. The review of systems is otherwise noncontributory.
Physical examination reveals dozens of fleshy nodules of 0.5-2.0 cm throughout her trunk, face, and upper extremities. The nodules are nontender to palpation and nonerythematous, and they produce no discharge, crusting, or scaling. Several 1.5- to 3-cm, tan, oval macules and patches with well-defined borders are located on her trunk and upper extremities (see Images). Her vital signs are within normal limits, and the rest of the physical findings are unremarkable.
Diagnosis?
• Neurofibromatosis (NF) is an autosomal dominant disorder with numerous presentations affecting nearly every organ system. The 2 major subtypes are
1) NF type 1 (NF1), also known as peripheral NF, also known as von Recklinghausen disease, involving a gene mutation on chromosome 17,
And
2) NF type 2 (NF2), referred to as central NF, which results from an abnormality of chromosome 22.
. Other findings in NF:
NF 1:
• Multiple cutaneous neurofibromas
• Soft papillomas
• Café au lait patches
• Axillary freckling
• Iris fibromas
• Plexiform neurofibromas
• Spinal neurofibromas
• Aqueduct stenosis
• Scoliosis
• Endocrine tumors
Management:
• No cure exists for this condition. Recommendations for follow-up include referral to support groups, psychological counseling, evaluation of learning disorders, surgical excision of lesions, and regular monitoring by a primary care provider for any changes that may occur, as patients with NF1 are at somewhat increased risk of malignancy. Annual ocular examinations are recommended. Genetic testing is also advocated in patients with NF who wish to have children. Surgery has been a successful treatment for the lesions themselves; however, recurrence often occurs, and nerve damage is a risk when tumors are located along neural pathways
Case 5:
• A 54-year-old African-American woman presents to her primary care physician"s office with a history of right-sided chest discomfort and intermittent dry cough of 4 weeks" duration. She denies having a fever, chest pressure, night sweats, hemoptysis, or weight loss. However, she does admit to a 25-pack-year history of smoking and denies using any illicit drugs. She has not recently traveled outside the United States.
On physical examination, she is afebrile with a normal heart rate and blood pressure. She is a well-developed, thin woman who appears to be in no apparent distress. Findings from the patient"s lung and heart examination are unremarkable. Findings from the remainder of the examination are also unremarkable.
The chest radiograph (see Image 1) demonstrates a cavitary mass in the right upper lobe of the lung. Follow-up chest CT (see Image 2) shows the same cavitary mass as a thick-walled lesion in the posterior segment of the right upper lobe. It measures 4.2 X 5.5 cm.
The patient is initially given a 2-week course of oral clindamycin. However, follow-up chest images obtained approximately 1 month afterward fail to reveal any interval improvement. A positron emission tomographic (PET) scan is subsequently obtained and shows abnormal [18F]-fluorodeoxyglucose (FDG) uptake in the right posterior and apical segments of the right upper lobe and right hilar lymph node with no other foci of abnormal uptake. Ultrasonography-guided aspiration and core lung-mass biopsy are performed, but the results are nondiagnostic.
The patient eventually undergoes thoracotomy and right upper lobectomy. Biopsy specimens are obtained. The pathology specimen shows evidence of acute necrotizing bronchopneumonia and a cavitary abscess. Silver staining demonstrates aggregates of filamentous organisms (see Image 3).
Diagnosis?
Pulmonary actinomycosis:
• Pulmonary actinomycosis is commonly confused with TB, suppurative lung disease, and malignancy. Patients with pulmonary actinomycosis usually present with a pulmonary consolidation. However, as in this case, some patients present with cavitation and spread to the adjacent tissues. Bronchoscopic findings are usually nondiagnostic, and most patients require open lung biopsy. The organism involved in this condition is Actinomyces israelii. This microorganism is slender, branching gram-positive bacillus embedded in the matrix of the sulfur granules. The hallmark of actinomycosis is the formation of the yellow sulfur granules.
Differential diagnosis of a cavitary lung mass
• The differential diagnosis of a cavitary lung mass consists of a wide variety of pulmonary diseases. Some, such as bronchogenic carcinoma, tuberculosis (TB), and suppurative lung disease, are common, and others, such as actinomycosis, are relatively infrequent.
Treatment:
• Penicillin G is the drug of choice. Ten to 20 million units are give via a parenteral route for 4-6 weeks, followed by oral penicillin V, 500mg four times daily. Alternatives include ampicillin, 12g/d IV for 4-6 weeks followed by oral amoxicillin 500mg thrice daily.
• Response to therapy is slow therapy should be continued for weeks to months after clinical menifestations have dissapeared in order to endure cure.
• Surgical procedures such as drainage and resection may be beneficial.
Case 6:
• A 56-year-old edentulous woman presents to a private dental clinic for a denture fitting. The patient has a masklike facies and a forward and stooped posture with involuntary lip smacking and tongue protrusion. She is apprehensive and has difficulty cooperating during examination of the intraoral cavity because of impulsive movements of her mouth and tongue (see Images).
On questioning, the patient reports a long history of depression, with intermittent complications of psychotic features. She reports a generalized decrease in her sleep, with difficulty falling asleep and early morning wakening. Her appetite has also decreased, and she has noticed slowing of all her movements over the past year. She is currently taking clonazepam, amoxapine, and piracetam, but has previously received several antipsychotic drugs, including risperidone, trihexyphenidyl, and buspirone.
What is the diagnosis?
Diagnosis?
• Tardive dyskinesias
Case 7:
• An 82-year-old man presents to the clinic with progressive difficulty swallowing and dysphagia over the last several weeks. He has been unable to eat food or drink water for the last 6 days and is thirsty. He denies odynophagia but reports that his speech has become slurred concurrently with his other difficulties. He denies having motor or sensory deficits, headache, fevers, urinary symptoms, malaise, or fatigue.
On physical examination, the patient"s vital signs are normal with a heart rate of 78 beats per minute and a blood pressure of 132/67 mm Hg. Pulse oximetry is 98% on room air. He has slurred speech. Examination of the head and neck reveals a normal oropharynx with intact tongue movements and a preserved gag reflex. However, the patient has bilateral, symmetric palpebral ptosis with a masklike face. In addition, he has to tilt his head back to look straight ahead. Because of an inability to lift his eyelids, he seems to be furrowing his eyebrows to compensate.
The patient has normal motor strength, including strength in the extensors of his wrist and deltoids. He has intact sensation in his extremities and symmetric and normal deep tendon reflexes, and he can walk with no pronator drift. The patient has no difficulty breathing.
Diagnosis?
• Myasthenia gravis
Case 8:
• A 32-year-old man presents to the emergency department with an itchy and painful rash on the back of his left leg (see Image). About 7 days ago, he began to feel an “intense, burning” pain behind his left knee. Over the subsequent days, “small blisters” began to “pop up” over the area but were the worst behind the knee itself. He treated the lesion with an over-the-counter antibiotic ointment and acetaminophen (Tylenol), but they did not relieve the pain.
Any contact, however slight, with the apparent blisters immediately intensifies the pain. The patient reports having fevers, sneezing, and a runny nose over the last 2 weeks. He does not report any cough, shortness of breath, headaches, or fatigue. He also reports extreme stress at work with many deadlines and an ongoing threat of job loss because of continuing downsizing due to overseas corporate operations. He denies exposing the affected area to heat or cold (burn) or to chemical agents, including detergents or cleaning agents. He has not started taking any new medications recently and is currently taking only acetaminophen. He has no known drug allergies, he quit smoking tobacco several years ago, and he drinks alcohol only rarely. His medical history is significant only for an appendectomy.
On physical examination, the patient’s vital signs are a temperature of 37.2°C, a heart rate of 82 beats per minute, and a blood pressure of 124/67 mm Hg. Lesions are observed on the back of the left knee (see Image), and similar but smaller lesions appear in a bandlike distribution along the posterior length of his left leg up to the buttock region. The affected leg is neurovascularly intact. Remaining findings on neurologic examination, cardiorespiratory examination, and the review of systems are unremarkable
Diagnosis?
Case 9:
• A 61-year-old man presents with a chief complaint of painless hematuria. He has had 6 episodes over the past 2 years. For approximately 1 day, he had several episodes of hematuria followed by the passage of blood clots the next morning. He denies having trauma, flank pain, dysuria, urinary frequency, fevers, or weight loss. He denies traveling outside the country. He has not had any recent surgery, catheterization, or other procedure involving instrumentation. He has no chronic medical problems and specifically denies a history of renal stones. He denies drug use, including over-the-counter analgesics. He smoked cigarettes for 25 years but quit 2 years ago.
The patient"s physical examination is unrevealing. He has no palpable masses, abdominal or costovertebral tenderness, prostate enlargement or tenderness, or penile abnormality. Laboratory studies show mild normocytic anemia with a normal coagulation profile. Urinalysis reveals a large amount of RBCs with no nitrites or detectable leukocyte esterase.
Intravenous pyelography (IVP) (see Image 1) and CT scanning at the level of kidneys (see Image 2) are performed.
Diagnosis?
• TCC arises from the contiguous transitional epithelium that lines the urinary tract from the renal pelvis to the bladder. The disease accounts for 90% of tumors arising in the upper urinary tract. About 24-44% of upper-tract tumors are associated with multifocal disease. TCC is up to 3 times more common in men than in women and twice more common in Caucasians than in African-Americans. The incidence peaks between the sixth and seventh decades of life, and TCC is rare before the age of 40 years.
Risk Factors:
• Cigarette smoking appears to be the greatest risk factor for TCC and is thought to be responsible for 70% of cases in men and 40% of cases in women.
• Other risk factors are
* chronic or recurrent urinary infections,
* urinary stasis in the presence of a horseshoe kidney, and
* exposure industrial chemicals (eg, aniline dyes, petrochemicals, plastics, coal, tar, asphalt).
* Analgesic abuse increases the risk of TCC 20-fold; of particular note is the development of papillary necrosis with the use of phenacetin.
* The chemotherapy drugs cyclophosphamide and ifosfamide are believed to be associated with TCC, especially after drug-induced hemorrhagic cystitis occurs.
Differential diagnosis for a filling defect (Large arrow) in the renal pelvis
• transitional cell carcinoma,
• calculus,
• sloughed papilla,
• an air bubble, and
• a fungal ball
Clinical Presentation:
• At least 75% of patients present with a history of gross or microscopic hematuria.
• Approximately 14-37% of patients have flank pain, which is typically described as dull with a slow, progressive onset that occurs as the collecting system dilates.
• Some patients have an abrupt onset of colicky pain mimicking that associated with renal stones; this pain results as blood clots acutely obstruct the collecting system.
• As many as 10-15% of cases are found incidentally in asymptomatic patients when imaging studies are performed for indications other than an evaluation of TCC.
• A few patients present with signs or symptoms of advanced disease, such as weight loss, anorexia, bone pain, or a mass.
Investigations:
• Urinalysis may demonstrate at least 2-5 RBCs per high-power field.
• Cytologic studies are generally not sensitive for the detection of upper-tract tumors.
• IVP studies demonstrate an irregular filling defect in the wall of the upper tract in 50-75% of patients. In 10-30% of patients, the tumor is obstructive and results in nonvisualization of the collecting system.
• Retrograde pyelograms are obtained in patients with renal insufficiency who cannot receive intravenous contrast material or in patients with high-grade obstructions that are poorly or not visualized on IVP.
• CT should be performed with and without intravenous contrast enhancement. The scans demonstrate a mildly enhancing mass in the renal pelvis that is relatively hypovascular compared with renal cell carcinoma. CT is also useful in ascertaining the local extent of disease and for locating metastases.
• Ureteroscopy is increasingly used for lateralization, localization, and excision of some renal pelvic masses.
Management:
• The pathologic stage of the disease, based on the depth of invasion, the extent of tumoral spread, and the histopathologic grade, determine the course of treatment.
• A father brings his 15-year-old son to the emergency department because of a large bruise over the son"s lower left ribs from being struck by a lacrosse ball during an inter-high school game. In addition to complaining of pain in the upper portion of his left abdomen, the patient also has pain in his left shoulder, which movement seems to aggravate. He is ambulatory and in no acute distress.
The triage nurse orders a chest radiograph, which is normal. The patient is triaged to fast-track care.
On physical examination, the patient has a blood pressure of 125/78 mm Hg, a heart rate of 106 beats per minute, and a respiratory rate of 12 breaths per minute. His temperature and oxygen saturation are normal. He has no trouble walking, but he seems to have a lot of pain while positioning himself on the bed. Findings from cardiorespiratory examination are unremarkable. He has diffuse abdominal tenderness that is most pronounced in the left upper quadrant. No rebound or guarding is observed. The patient has no tenderness to palpation over the left shoulder or clavicle, and he has full range of motion in that joint.
Presentation:
• Patients with splenic injuries may present with isolated left upper quadrant pain or diffuse abdominal tenderness. Referred pain to the left shoulder, as observed in this patient, is due to diaphragmatic irritation from subphrenic blood; this is known as the Kehr sign. Severe hemorrhage may cause abdominal distension and frank shock. A presentation delayed by more than 48 hours after trauma may cause additional findings, such as jaundice or left pleural effusion
Grading:
• Traumatic splenic injuries are graded I-V according to their severity, as evaluated on CT imaging.
• A grade I injury is a subcapsular hematoma of less than 10% of the surface area or a laceration that is less than 1 cm deep.
• If both of these findings are present, the injury is grade II. A grade II injury is also a subcapsular hematoma of 10-50% of the surface area, an intraparenchymal hematoma of 5-cm diameter, or a laceration 1-3 cm deep. If 2 grade II injuries are present, the severity is grade III.
• A grade III injury is also defined as a subcapsular hematoma of greater than 50% of the surface area, a parenchymal hematoma that is larger than 5 cm in diameter, or a laceration that is deeper than 3 cm or that involves the trabecular vessels
• A grade IV injury is a laceration that involves segmental or hilar vessels that produces >25% organ devascularization.
• A grade V injury is a completely shattered or completely devascularized spleen.
Management:
• Patients in hemodynamically unstable condition with signs of intraperitoneal bleeding should receive aggressive fluid resuscitation and/or blood products
• Surgical management by means of laparotomy is indicated if hemodynamic instability is observed or if the patient requires massive transfusion (transfusion of packed red blood cells of >40 mL/kg in a child or of >2 units in an adult
• In the hemodynamically stable patient, the higher the grade of injury, the more likely the need for surgery. Most grade IV or V injuries require surgical care, as do some low-grade injuries depending on a variety of circumstances, including comorbidity, concomitant injury, hospital resources (eg, angiographic and surgical capabilities), and acceptability of blood transfusion to the patient.
• Nonsurgical observation is a safe practice that improves outcomes in for hemodynamically stable patients with blunt solid-organ injuries. In addition, preservation of the spleen avoids the subsequent risk of infections with encapsulated organisms, such as Streptococcus, Neisseria, and Haemophilus species. Overall, less than 10% of children with splenic injuries ultimately require surgery.
Case 4:
• 33-year-old woman was evaluated because of persistent pulmonary infiltrates. She was well until 7 months ago, when she developed fever, a productive cough, and left-sided pleuritic chest pain. A chest radiograph showed an infiltrate in the left lower lobe. Several courses of antibiotics led to an improvement of her symptoms, though a dry cough persisted. Subsequent chest CT showed attenuating airspace disease in the left lower lobe with air bronchograms and ill-defined nodules in both lungs. Before her current presentation, she underwent 2 bronchoscopic procedures, with transbronchial biopsy performed during the most recent one. All bacterial cultures were negative, and cytology and pathology failed to reveal malignancy. Given the lack of an infectious etiology, corticosteroids were started. However, the patient"s condition did not improve.
On evaluation in the emergency department, the patient was asymptomatic except for a persistent cough with clear sputum. She was a nonsmoker and had no previous pulmonary disease. She did not have a history of tuberculosis or known exposure to risk factors. A purified protein derivative of tuberculin (PPD) test performed 3 months ago yielded negative results. She has not been taking any drugs and has no known allergies. Physical examination revealed a well-appearing woman in no distress with a respiratory rate of 16 breaths per minute, a temperature of 35.9°C, a blood pressure of 110/60 mm Hg, and a heart rate of 95 beats per minute. Her lungs were clear, with no wheezing, rhonchi, or rales. Her heart sounds were normal, with no murmurs. The remainder of her examination yielded unremarkable findings.
Chest CT was performed (see Image). Positron emission tomography (PET) showed increased uptake in the left posterior portion of the lower lung with a standard uptake value (SUV) of 6.5 and no uptake in the nodules or hilar or mediastinal nodes.