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A 78-year-old woman presents to your urgent care clinic with new onset palpitations that began a few hours before presentation.
Upon examination, you find:

  • Pulse is 123
  • Blood pressure is 152/83
  • The only existing issue she admits is hypertension, for which she is taking thiazides as

Consider Figure 1, above, and what your possible diagnosis might be, based on the evidence available. Resolution of the case is on the next page.


The patient is experiencing irregular supraventricular rhythm, with a variable rate 125-175; most probably, atrial fibrillation (though it could be atrial flutter with variable block). The ST changes seen are most probably rate related.
However, if the clinical picture is highly suggestive, ischemia must be ruled out

Clinical Challenge 2 : February, 2007