Physical Exam //

MEDICAL DECISION MAKING / RE-EVALUATION The patient presents in atrial fibrillation with rapid ventricular response with an onset of known certainty to be less than 48 hours. During the Emergency department course the patient's rate was controlled with *** . A full cardiac workup was performed showing no evidence of life threatening or serious causes of the patient's atrial fibrillation. Patient elected to undergo electrical cardioversion under conscious sedation. Procedure: Electrical Cardioversion of Atrial Fibrillation Indications: Atrial fibrillation. Contraindications: ***clinical CHF, EF <35%, known embolic event, digoxin >= 2.0, Afib/aflutter >48 hours and not on warfarin Consent Obtained: Risks of procedure as well as the alternatives and risks of each were explained to the (patient/designee). Patient consented and agreed to procedure with associated conscious sedation. Patient identification confirmed by patient name and medical record number on ID bracelet, and by verbal verification of name by patient. Procedure and site confirmed confirmation by patient, nurse and physician Patient placed on cardiac monitor, pulse oximetry, supplemental oxygen as necessary. Sedation given: See Procedural Sedation documentation Paddles placed: on anterior chest Cardioverted { :25573} time(s). Cardioverted at: { :25574} Complications: none Findings: Post procedure EKG shows: {REQUIRED:25578} Patient tolerated procedure well. On reevaluation, the patient was found to be in NSR, was alert and denied having chest pain or other complaints.



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