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A 67-year-old man presents to the ER with palpitations and dyspnea which began approximately 4 hours ago. He has a history of HTN, left ventricular hypertrophy, Diabetes, and GERD. His current medications are lisinopril, metformin, and omeprazole. He has no history of stroke or TIA. He is accompanied by his wife who reports drinking 1 pot of coffee daily and 1-2 beers on the week-ends. He does not binge drink or use herbal or alternative mediations. His wife reports he snores and has daytime sleepiness. He quit smoking 10 years ago.
He appears to be in mild respiratory distress. Blood pressure is 88/60mmHg, pulse rate is 140 bpm, respiratory rate is 24/min, and temperature is normal. Oxygen saturation is 90% on 40% oxygen by face mask. His BMI is 36. Cardiac exam reveals tachycardia with an irregularly irregular tachycardic rhythm. There are crackles in the lower lung fields. A chest radiograph does not show infiltrates, pleural effusions, masses, blebs, or hyperinflation.
Laboratory analysis reveals normal thyroid function, D-dimer and cardiac biomarkers.
Electrocardiogram demonstrates atrial fibrillation (AF) with rapid ventricular rate.
1. Considering the physical exam and in the subjective report, what risk factors did you note for the development of an arrhythmia in this patient?
2.  What discharge teaching would you include for this patient and family?

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