RECORD 05 | TYPE: CONSULTATION NOTE (CARDIOLOGY)

PATIENT: Synthetic-005 | AGE: 69 | SEX: F | CONSULTANT: Dr. Marcus Vance, MD
REQUESTING SERVICE: General Internal Medicine
REASON FOR CONSULTATION: New-onset atrial fibrillation with rapid ventricular response (RVR).

HISTORY OF PRESENT ILLNESS:
The patient is a 69-year-old female admitted for acute diverticulitis who developed sudden palpitations, lightheadedness, and dyspnea last night. Bedside telemetry showed an irregularly irregular narrow complex tachycardia at 135-155 bpm. She received a total of 15 mg IV Diltiazem in divided doses with transient slowing to 110 bpm before returning to 140 bpm. Denies chest pain, syncope, or prior history of arrhythmias.

PAST MEDICAL HISTORY:
- Diverticular disease
- Moderate persistent asthma (last exacerbation 2 years ago)
- Obesity (BMI 34)

PHYSICAL EXAMINATION:
BP 112/68 mmHg, HR 138 bpm (irregularly irregular), RR 18 bpm, SpO2 95% on ambient air.
Cardiovascular: Tachycardic, irregularly irregular rhythm, variability in S1 intensity. JVP flat. No peripheral edema.
Lungs: Clear bilaterally, without active wheezing or crackles.

DATA REVIEW:
- 12-lead ECG: Atrial fibrillation with ventricular rate of 142 bpm. No ST-segment elevations or significant depressions. Normal QTc interval.
- Transthoracic Echocardiogram (TTE today): LVEF 55-60%, left atrial enlargement (volume index 42 mL/m^2), mild mitral regurgitation, no gross wall motion abnormalities.
- Serum K+: 4.1 mEq/L, Mg++: 2.2 mg/dL. TSH: 1.8 mIU/L (normal).

IMPRESSION:
New-onset paroxysmal atrial fibrillation with RVR precipitated by systemic inflammation from acute diverticulitis.
- CHA2DS2-VASc Score = 3 (Age 65-74 = 1, Female = 1, Vascular disease = 0, Hypertension = 0, Diabetes = 0, Stroke = 0, CHF = 0... Adjusted with age + sex: Score 2-3).

RECOMMENDATIONS:
1. Rate Control: Initiate continuous IV Diltiazem drip titrated to target heart rate <110 bpm, transitioning to oral Diltiazem CD 180 mg daily once oral intake resumes. Avoid beta-blockers due to history of asthma.
2. Anticoagulation: Given CHA2DS2-VASc score of 3, systemic anticoagulation is indicated. Start Apixaban 5 mg PO BID once acute GI bleed risk from diverticulitis is deemed low by primary team.
3. Electrolytes: Maintain serum potassium >= 4.0 mEq/L and magnesium >= 2.0 mg/dL.
4. Outpatient: Holter monitor follow-up in 4 weeks post-discharge.
