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A 70 year old man with chronic obstructive pulmonary disease and hypertension was admitted to hospital with a two month history of worsening dyspnoea on exertion and ankle swelling. On examination, the patient was in atrial fibrillation with an apical ventricular rate of 136 beats/min. The jugular venous pressure was not visible, but there was bilateral pitting oedema to the knees. Auscultation of the chest revealed polyphonic wheeze and poor air entry but no crepitations.
An electrocardiogram (ECG) confirmed atrial fibrillation.
Full blood count, urea and creatinine, liver and thyroid function tests, and bone profile were all within normal limits. The plasma magnesium was 0.56 mmol/l.
The patient was treated with oral digoxin, intravenous frusemide, and nebulised salbutamol.
Within 24 hours of admission, the patient had a cardiac arrest and was successfully resuscitated. Three further cardiac arrests involving a similar rhythm disturbance occurred during the second day.
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