American College of Physicians: Internal Medicine — Doctors for Adults ®


The MKSAP Challenge

From the December ACP Observer, copyright 2003 by the American College of Physicians.

Clinical scenario

A 77-year-old man is found to have asymptomatic atrial fibrillation on a routine examination. His medical history includes hypertension, hypercholesterolemia, diabetes mellitus and osteoarthritis, but he has no history of heart disease. His medications include atenolol and simvastatin.

He weighs 72 kg (159 lb), blood pressure is 138/76 mm Hg and resting ventricular rate is 78/min. On examination, his jugular venous pressure is less than 5 cm H2O. His lungs are clear. There are no cardiac murmurs or gallops. There is no edema.

Neurologic evaluation, including mental status examination and gait, is normal. An echocardiogram shows no wall motion abnormalities, and the ejection fraction is 45%. Thyroid studies are normal.

What is the most appropriate next step in the management of this patient?

A. Initiation of therapy with warfarin, 5 mg/d.
B. Referral for cardioversion and maintenance with low-dose amiodarone therapy.
C. Initiation of therapy with aspirin, 325 mg/d.
D. Three days of warfarin, 10 mg/d, followed by 5 mg/d.
E. Simultaneous initiation of therapy with low-molecular-weight heparin and warfarin, 5 mg/d.



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