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"I've never been so weak in my life."

60 year old male with no known medical history (has not seen physician in many years) presents to the hospital with weakness and shortness of breath.

On arrival to the ED, he is noted to be very tachycardic, with a heart rate in the 150-160s. EKG revealed atrial flutter. He is started on metoprolol with no improvement, then on diltiazem drip which is increased to the maximum rate but his heart rate doesn't budge.

The ER doctor has consulted cardiology and is awaiting a call back. In the meantime, you are called to admit the patient.


T 98.4 HR 162 BP 152/78 RR 25 SPO2 98% on RA


Gen: in moderate respiratory distress but speaking in full sentences, appears uncomfortable

CVD: very tachycardic, unable to discern murmurs

Lung: crackles bilaterally

Abd: snt

Extremities: trace edema bilaterally


WBC 65,000 (5% bands, 60% neutrophil)

Hgb 10

Plt 2100

BUN 20

Cr 1.1

Trop 0.0

BNP 208

LDH 1500



Parasternal long

Parasternal short



What is the next step in management?

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