Clinical Evaluation

One should always start with a detailed clinical history and physically oriented examination.  A past medical history of hypertension, hyperlipidemia, diabetes, chronic obstructive lung disease (COPD with cor pulmonale), ischemic heart disease, rheumatic heart disease, thyroid dysfunction, or malignancy would be highly relevant to elicit.  A careful social history, use of alcohol, tobacco, and drugs should follow.  Risk factors for pulmonary embolism (travelling, immobilisation), symptoms of palpitation, congestive heart failure, infectious state, as well as thyroid dysfunction (diarrhea, weight lost) should all be included in the review of systems.

On physical examination, one should concentrate on the cardiovascular, pulmonary, abdominal, and neurological exam.  The vitals signs could reveal a high temperature, and an irregularly irregular fast heart rate.  Close attention should be given to the present of an elevated jugular venous pressure with loss of the a wave, a displaced point of maximal impulse, cardiac murmurs, pulmonary crackles or wheezing, and finally focal neurological deficits.  The abdominal exam could reveal ascites, a positive hepatojugular reflex and pulsating liver consistent with liver congestion.  Presence of lower leg edema could also be manifested and should be examined for carefully.

The diagnosis of atrial fibrillation need to be made on surface electrocardiogram “ECG” demonstrating an irregularly irregular narrow complex with the absence of p wave (Picture 1).

 Picture 1. ECG of Atrial Fibrillation
ECG of afib

The patient then require routine blood work including a CBC (looking for sign of infection), electrolytes, liver/renal function, thyroid function, echocardiogram (looking for structural heart disease and intracardiac thrombus), a chest x-ray (looking for any sign of dilated heart, and/or increase pulmonary vasculature), and finally a spiral ct chest to rule out pulmonary embolism in the appropriate clinical setting.


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