CASE STUDY FOR JOSEPH MARTINEZ
68 YEARS OLD MALE WITH (“HEART
POUNDING X 3 Days AND “SHORTNESS
OF BREATH”) COMBINED REASON FOR
ENCOUNTER EXPERT CASE REVIEW
LATEST 2025-2026.
Joseph Martinez A 68 year old male with REASON FOR
ENCOUNTER
"heart pounding x 3 days" and shortness of breath.
bp 150/100 HR 136
1. What labs and test would you order?
2. Medications? IVP Metoprolol, Cardizem drip or Amio
drip
Start Heparin drip or PO eliquis
A 68-year-old male patient presenting with "heart pounding for 3 days" and
shortness of breath, with a blood pressure of 150/100 mmHg and heart rate of 136
bpm, this suggests a potential arrhythmia, such as atrial fibrillation with rapid
ventricular response (Afib with RVR), or other cardiac causes like supraventricular
tachycardia. The following labs, diagnostic tests, and treatments would be
appropriate:
Labs and Tests
1. Electrocardiogram (ECG): Urgent to confirm the rhythm (Afib, SVT, etc.).
, 2. Chest X-ray (CXR): To assess for any underlying pulmonary causes like
heart failure or infection.
3. Complete Blood Count (CBC): To check for anemia or infection.
4. Basic Metabolic Panel (BMP): To evaluate electrolytes (especially potassium
and magnesium), kidney function, and glucose.
5. Cardiac enzymes (Troponin, CK-MB): To rule out myocardial infarction.
6. Thyroid function tests (TSH, free T4): Hyperthyroidism can precipitate
arrhythmias.
7. B-type natriuretic peptide (BNP): To assess for heart failure.
8. D-dimer (if pulmonary embolism is suspected).
Medications and Treatment Options
Acute Management:
1. Rate Control:
o IV Metoprolol (Beta-blocker): Helps to control the heart rate in atrial
fibrillation or other tachyarrhythmias.
Dose: 2.5-5 mg IV push over 2 minutes, repeat as needed.
o IV Cardizem (Diltiazem) (Calcium channel blocker): Used for rate
control in Afib with RVR, especially in patients where beta-blockers
are contraindicated.
Bolus: 0.25 mg/kg IV over 2 minutes, then an infusion at 5-15
mg/hour.
o Amiodarone drip: Can be used if there is concern for rhythm control
or if the patient is unstable or refractory to other treatments.
Load: 150 mg IV over 10 minutes, then 1 mg/min for 6 hours,
followed by 0.5 mg/min.
2. Anticoagulation:
o Heparin drip: Initiate if there is concern for a thromboembolic event
due to atrial fibrillation, especially if this is a new onset. A bolus
followed by a continuous infusion can be started with weight-based
dosing and titrated based on PTT levels.
o PO Eliquis (Apixaban): This may be considered if the patient is stable,
without a need for urgent reversal, and has no contraindications for
long-term anticoagulation (used for long-term stroke prevention in
Afib).
Dose: Typically 5 mg twice daily (adjust based on renal
function and patient profile).
Additional Considerations
Electrolyte correction (potassium and magnesium): Ensure these are within
normal ranges to prevent further arrhythmias.
Oxygen therapy: If the patient is hypoxic or in respiratory distress.
Monitor closely: Continuous cardiac monitoring and repeat ECG to assess
response to treatment.
68 YEARS OLD MALE WITH (“HEART
POUNDING X 3 Days AND “SHORTNESS
OF BREATH”) COMBINED REASON FOR
ENCOUNTER EXPERT CASE REVIEW
LATEST 2025-2026.
Joseph Martinez A 68 year old male with REASON FOR
ENCOUNTER
"heart pounding x 3 days" and shortness of breath.
bp 150/100 HR 136
1. What labs and test would you order?
2. Medications? IVP Metoprolol, Cardizem drip or Amio
drip
Start Heparin drip or PO eliquis
A 68-year-old male patient presenting with "heart pounding for 3 days" and
shortness of breath, with a blood pressure of 150/100 mmHg and heart rate of 136
bpm, this suggests a potential arrhythmia, such as atrial fibrillation with rapid
ventricular response (Afib with RVR), or other cardiac causes like supraventricular
tachycardia. The following labs, diagnostic tests, and treatments would be
appropriate:
Labs and Tests
1. Electrocardiogram (ECG): Urgent to confirm the rhythm (Afib, SVT, etc.).
, 2. Chest X-ray (CXR): To assess for any underlying pulmonary causes like
heart failure or infection.
3. Complete Blood Count (CBC): To check for anemia or infection.
4. Basic Metabolic Panel (BMP): To evaluate electrolytes (especially potassium
and magnesium), kidney function, and glucose.
5. Cardiac enzymes (Troponin, CK-MB): To rule out myocardial infarction.
6. Thyroid function tests (TSH, free T4): Hyperthyroidism can precipitate
arrhythmias.
7. B-type natriuretic peptide (BNP): To assess for heart failure.
8. D-dimer (if pulmonary embolism is suspected).
Medications and Treatment Options
Acute Management:
1. Rate Control:
o IV Metoprolol (Beta-blocker): Helps to control the heart rate in atrial
fibrillation or other tachyarrhythmias.
Dose: 2.5-5 mg IV push over 2 minutes, repeat as needed.
o IV Cardizem (Diltiazem) (Calcium channel blocker): Used for rate
control in Afib with RVR, especially in patients where beta-blockers
are contraindicated.
Bolus: 0.25 mg/kg IV over 2 minutes, then an infusion at 5-15
mg/hour.
o Amiodarone drip: Can be used if there is concern for rhythm control
or if the patient is unstable or refractory to other treatments.
Load: 150 mg IV over 10 minutes, then 1 mg/min for 6 hours,
followed by 0.5 mg/min.
2. Anticoagulation:
o Heparin drip: Initiate if there is concern for a thromboembolic event
due to atrial fibrillation, especially if this is a new onset. A bolus
followed by a continuous infusion can be started with weight-based
dosing and titrated based on PTT levels.
o PO Eliquis (Apixaban): This may be considered if the patient is stable,
without a need for urgent reversal, and has no contraindications for
long-term anticoagulation (used for long-term stroke prevention in
Afib).
Dose: Typically 5 mg twice daily (adjust based on renal
function and patient profile).
Additional Considerations
Electrolyte correction (potassium and magnesium): Ensure these are within
normal ranges to prevent further arrhythmias.
Oxygen therapy: If the patient is hypoxic or in respiratory distress.
Monitor closely: Continuous cardiac monitoring and repeat ECG to assess
response to treatment.
