Case History : A 63 year old female presents to your OPD with complaints of Dizziness, palpitations a A 63 year old female presents to your OPD with complaints of Dizziness, palpitations and apprehension. She also complaints of difficulty in breathing , a dry cough and retro sternal discomfort.

 A 63 year old female presents to your OPD with complaints of Dizziness, palpitations and apprehension. She also complaints of difficulty in breathing , a dry cough and retro sternal discomfort.

Her pulse is 130 beats/ minute and Blood pressure is 145/90 mmHg. Oxygen saturation is 92 percent .

Temperature is 37 C.

Chest is clear on auscultation.

On examination :

She has a goitre visible, mainly in the midline.

There is mild putting oedema of the feet.

An ECG is done, which is shown below:

1. What are the findings in the ECG?

2. What further investigations should be performed?

3. What is the most likely Diagnosis?

4. How should this patient be managed?

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Anonymized data with consent taken for teaching purpose.

Answers in comments section.

1. Findings in the ECG:

Irregular R-R interval.

Absent p waves.

Heart rate varying between 110-125 BPM.

2. Further investigation:

Thyroid function Tests

Ultrasound of Thyroid gland and Radio iodine uptake scan if Thyroid function Tests show Thyrotoxicosis.

Chest X rayFull blood countSugar and Cholesterol levelsPro BNP and Echocardiogram.

3. Most Likely Diagnosis

Atrial fibrillation.

Most likely Thyrotoxicosis

4 .Management

Since patients Blood pressure is stable, first line of management would be chemical cardioversion. Medication of choice include:

Bisoprolol 2.5 - 5 mg BD Other options include: Digoxin. and IV Metoprolol 5 mg .

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