1601006043 LONG CASE

 

PALPITATIONS IN 47 Y/O MALE

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CHIEF COMPLAINT : 47 y/o businessman with palpitations since last 5 days. 

PRESENT HISTORY : 

Pt was apparently asymptomatic 5 days ago after which he experienced sudden onset awareness of his heart beat accompanied by impending sense of doom, which was irregular and forceful in nature ; occurring intermittently over the course of past 5 days, (irrespective of rest/active) - lasting a duration of 5-10 minutes and regressing spontaneously ; perceived more during evening ; 

Associated with difficulty in breathing even at rest / not strenuous activity 

It is not associated with any triggers like strenuous exercise/ intake of anti-diabetic medication or fasting / consumption of tea and coffee / vomiting and diarrhoea 

No h/o  associated dizziness , headache, chest pain and fainting / tingling in hands and face / polyuria 

He is not sure if it is associated with sweating, he describes himself as someone who is almost always perspiring.

He gives a h/o significant weight loss in the last 1 month 

H/o anxiety wrt health and stress about family issues - sent for a psychiatry referral which indicated towards a probable panic attack

PAST HISTORY : 

Pt was diagnosed with B/L CAP with ARDS 1 month ago, for which he was on ventilator for 20 days during which he had an acute MI. 

He was given medication for one week following discharge which was discontinued immediately for reasons unknown

K/c/o HTN and DM since 10 years, on medication.

FAMILY HISTORY : 

Mother is k/c/o HTN and DM 

PERSONAL HISTORY :

  • Diet - Mixed 
  • Appetite - Normal 
  • Bowel & Bladder - Regular 
  • Sleep - Markedly reduced after discharge from hospital, sleeps only with sleeping pills. 
  • Addictions - None 
  • Drug / Food Allergies - H/o anaphylaxis to Valproate ( DICORATE ER)
DRUG HISTORY : 

Currently the patient is on 

  1. Antiplatelets 
  2. Statins
  3. Anti-Arrhythmics
  4. Benzodiazepine 
Along with 

  1. Anti-HTNives 
  2. OHAs
CASE SUMMERY

47 y/o male k/c/o DM and HTN on medication since 10 years with h/o  unprovoked intermittent Palpitations and Grade III - IV SOB which regress spontaneously within 5 to 10 minutes with significant wt loss in last 1 month and h/o ?panic attack as per psychiatry dept referral

GENERAL EXAMINATION : 
Pt is Conscious, coherent and cooperative ; oriented to time,  place and person ; moderately Built and Moderately Nourished 
No pallor/icterus/cyanosis/clubbing/lymphadenopathy/edema 











Vitals - 
A febrile
Resp. Rate - 17 cycles per minute
HR - 100 bpm
BP - 90/70 mm Hg 




No thyroid enlargement or visible pulsation in the neck
No cervical lymphadenopathy
No Tremors
Skin all over the body is normal 
All peripheral pulses felt 

SYSTEMIC EXAMINATION

CVS :
Apex felt in 5th ICS but lateral to mid clavicular line 
S1, S2 heard 
No murmurs 





Resp : 

Trachea - central with B/L air entry present 
Symmetrical expansion of the chest with each breath
Normal breath sounds, no wheeze/ crackles 
Vocal resonance Normal and symmetrical


 

Gastro-Intestinal : 

Pendulous Abdomen - soft non tender
No visible pulsation
No VGP
No organomegaly 
Bowel Sounds present 

CNS : 

Patient Conscious with HMF intact
Cranial Nerves - N
Motor and Sensory System - N
Cerebellum - N 

PROVISIONAL DIAGNOSIS :

47 y/o male  k/c/o HTN and DM with palpitations secondary to 
  • CARDIAC - ?MI (as a post MI complication) 
  • METALBOLIC - ?Hypoglycaemia
  • ENDOCRINE - 
  1. ?Thyroid Dysfunction 
  2. ? Pheochromocytoma
  • PSYCHIATRY - ?Anxiety Disorder 
INVESTIGATIONS : 


Previous investigations 



Investigations to be ordered 

1. Complete blood picture 
2. Hemoglobin 
3. Random Blood Sugar, HbA1c
4. TSH, T3, T4
5. Serum Creatinine, Urea
6. Electrolytes 
7. ECG 
8. Chest X-ray
9. Plasma metanephrines / 24 hr urinary metanephrines 

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