Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with intermittent episodes of palpitations, lightheadedness, and dyspnea. Episodes are self-terminating, lasting [duration], with no clear precipitating factors. Denies syncope, chest pain, or orthopnea. No prior history of stroke or TIA. Current anticoagulation status: [status].
Clinical Examination Findings
Cardiovascular: Irregularly irregular heart rhythm noted on auscultation. No murmurs, rubs, or gallops. Peripheral pulses are present and symmetric. No jugular venous distention. Lungs: Clear to auscultation bilaterally. Extremities: No peripheral edema noted.
Treatment Protocol
1. Rate control: [Beta-blocker/CCB] initiated. 2. Rhythm control: [Antiarrhythmic agent] as indicated. 3. Anticoagulation: CHA2DS2-VASc score calculated as [score]; initiated [DOAC/Warfarin] for stroke prophylaxis. 4. Follow-up: Holter monitor/Event monitor ordered to assess burden.