Signs of rhythm not converting spontaneously

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Reference no: EM132133303

Report 75 75. 2/12/XX JOYCE HARKNESS, MD, CONSULTING PHYSICIAN CHIEF COMPLAINT: Atrial fibrillation. Patient is a 68-year-old female, status post left total mastectomy for carcinoma of left breast. She has been doing fairly well postoperatively until this morning when she awoke with complaints of fluttering in the chest. ECG shows periods of rapid atrial fibrillation, with conversion to sinus rhythm spontaneously. Past history is positive for CAD and hypertension. Patient is status post coronary artery bypass × 3. No chest pain or anginal symptoms have been noted. Cardiac examination at present shows regular rate and rhythm; no gallops or murmurs are noted. ASSESSMENT: Atrial fibrillation, status post left total mastectomy. RECOMMENDATION: Treat conservatively with Coumadin at present. Monitor closely for signs of rhythm not converting spontaneously. Consideration would then have to be given to converting medically. Electrocardioversion is not recommended at this time. CPT Code(s): ______

Reference no: EM132133303

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