Ms. Jones is a 33-year-old female who is brought to the emergency department by EMS with a complaint of palpitations and shortness of breath for the past 1 hour.

History elements (these also indicate the questions that should be asked)

• No past medical history. Only medication patient is on is oral contraceptive pill.
• Symptoms started suddenly while she was watching TV, and have been constant since then.
• She has never experienced this before
• Mild, chest pain, of “tight” quality
• Dizziness (+)
• No family history of sudden cardiac death
• No recent travel, hospitalization, or other prolonged immobilization
• No syncope, fever, flu-like symptoms, or lymphadenopathy
• Smokes 1 ppd x 10 years
• Drinks 1 cup of coffee daily
• Denies other drug use.

Physical Exam (also indicates what procedures should be done)

• Vital signs – P225 bpm, BP145/86, R 22, T 98.7, SpO2 98% on room air
• Gen – alert, appears anxious, diaphoretic
• Pulm – tachypnea, CTA bilaterally. No adventitious breath sounds.
• Cardiac – tachycardia. Regular rhythm, although difficult to assess due to significantly fast pace of beats.
• Abd – BS +, no tenderness, no masses or rebound

Differential Diagnosis

• Supraventricular tachycardia – likely given the rate of the tachycardia, along with abrupt onset of symptoms with associated shortness of breath
• New onset atrial fibrillation – should be considered given the tachycardia and shortness of breath. Although less likely given heart rate is very high
• Pulmonary embolism – should be considered given the tachycardia and shortness of breath. Although less likely given SpO2 is 98% on room air.
• Drug use – pt denies but we can not always rely on the patient. Drugs like cocaine or other stimulants may produce these symptoms.
• Anxiety/panic disorder – diagnosis of exclusion, less likely given how high the heart rate is but

Tests (Student will be given results for any that are ordered):

• EKG

• Troponin – likely would not be ordered given EKG results showing SVT, thus probably increasing troponin levels secondary to oxygen demands of the heart
• D-Dimer – <0.30
• Chest XR – normal. Although likely would not be ordered given EKG results showing SVT

Diagnosis = supraventricular tachycardia

Treatment

• Put patient on a cardiac monitor
• Place pads in case electrical cardioversion is needed
• Trial of vagal maneuvers – pt was instructed to blow into a syringe. Unsuccessful.
• 6mg IV adenosine given – sinus rhythm was restored, rate now at 86 bpm