1601006050 LONG CASE

 A 47-year-old gentleman from Suryapet, who owns a transportation business, presented to the outpatient department with the :

Chief complaints: 

The patient came with the chief complaints of palpitation since last 3 days ago.

History of present illness: 

• The patient was apparently asymptomatic 3 days ago
• He then developed palpitations with each episode lasting for 5-10 minutes before disappearing spontaneously. 
• The nature of the heartbeat was described by the patient to be rapid, forceful, and irregular. 
• It was associated with anxiety, chest tightness, breathlessness, irritability, and exacerbated usually on sitting or even with trivial activity such as standing. 
• The episodes being more frequent in the evening. 
• It was not associated with sweating or syncope.
• He developed shortness of breath grade III/IV in association with palpitations, sudden onset rapidly progressive, spontaneously relieved on its own, occurring even at rest, and was not accompanied by chest pain, orthopnea or PND
• He gave a history of sweating a lot but it was not associated with the episodes of palpitation. 
• He has no history of

                -fatigue
                -cough, hemoptysis
                -dysphagia, hoarseness of voice 
                -high arched palate, chest deformity 
                -recurrent respiratory tract infections, fever, sore throat
                -fever, joint pains
                -tremors

• The patient also mentioned anxiety regarding family issues ( referred to psychiatry for opinion) which have led to disturbed sleep.

Past history : 

• The patient had a fever 2months ago following which he developed community-acquired pneumonia and had an episode of acute MI when he was admitted to the ICU. 
• The patient also gave a history of unintentional weight loss of 15 kgs after being put on a ventilator (from 90 to 75 kg).
• Known case of hypertension and diabetes mellitus ( controlled and currently under medication ) since 10 years
• No history of thyroid disorders, epilepsy, asthma, coronary artery disease, blood transfusions

Drug history -

• Antihypertensives - TELMISARTAN
• Oral hypoglycemic drugs - 
• METFORMIN 
• GLIMEPERIDE
• VOGLIBOSE
• Antiplatelets - 
• ASPRIN
• CLOPIDOGREL
• Antiarrhythmic drug - AMIODARONE
• Statins -ATORVASTATIN
• Allergic to Sodium valproate

Family history : 

The patient's mother is also a known case of hypertension

Personal history : 

• Appetite - normal 
• Diet - mixed
• Bowel and bladder - Regular
• Sleep- has disturbed sleep for the past 20 days after abruptly stopping his medications.
• Addictions - None
• No known food allergies

GENERAL EXAMINATION

The patient is conscious, cooperative, coherent, and well oriented to time, place, and person

He is well built (weighs 75kgs)  and well-nourished.

There was no pallor, icterus, cyanosis, clubbing, koilonychia, generalized lymphadenopathy, or pedal edema.

JVP is not elevated.

Hands - capillary refill time normal ( < 3 secs), feel dry and warm, no pallor, peripheral cyanosis, or finger clubbing.

Vitals

• Pulse: 90 beats per min, right radial pulse, regular, normal volume

• Blood pressure: 90/70 mmHg, measured on the right upper arm in sitting position

• Respiratory Rate :  18 cycles per min 
• Temperature: Afebrile
• No thyroid enlargement seen

SYSTEMIC EXAMINATION

Cardiovascular system

INSPECTION 

• Normal chest shape with no visible deformities

• The trachea is central in position
• No precordial bulgings
• No visible pulsations, scars, sinuses, or dilated veins seen.

PALPATION

• Apex beat located in left 5th intercostal space shifted outwards, lateral to the midclavicular line.

• No palpable heart sounds, thrills, or murmurs

AUSCULTATION

1. Mitral Area: 

Two Heart sounds heard. S1 and S2. S1 loud, S2 normal

2. Tricuspid Area:

Two heart sounds heard, S1 and S2 which are normal

Murmurs same as Mitral area but in lower intensity

3. Aortic Area:

Two heart sounds are heard, S1 and S2

No murmurs.

4. Pulmonary Area:

Two HS heard, S1 and S2.

S2 is louder than S1.

OTHER SYSTEMS:

Respiratory system 

• No chest wall deformity 
• Trachea central
• Expansion is symmetrical
• Percussion note is resonant
• Breath sounds normal, no wheeze or crackles heard.
• Vocal resonance normal and symmetrical

central nervous system

• Higher mental functions intact 
• Cranial nerves II- XII: Pupils equal and reactive to light, No abnormality detected.
• Speech normal
• 
  

  POWER	RIGHT		LEFT
  	UL	LL	UL	LL
  	5	5	5	5
  TONE	NORMAL	NORMAL	NORMAL	NORMAL
  LIGHT TOUCH	NORMAL	NORMAL	NORMAL	NORMAL
  POSITION	NORMAL	NORMAL	NORMAL	NORMAL
  COORDINATION	NORMAL	NORMAL	NORMAL	NORMAL

  
  

Abdominal system

• Normal oral mucosa.
• Abdomen distended , umblicus central 
• No scars, sinuses, or any engorged veins.
• Hemial orifices intact
• Tenderness or guarding absent
• No enlargement of liver, kidneys, or spleen
• No ascites
• Bowel sounds were normal
• PR not done.

Musculoskeletal system

• Gait is normal.
• No muscle or soft tissue changes.
• No bone or joint deformities.
• No limitation of movements.

 A brief summary

A 47 y/o male who is k/c/o hypertension and diabetes for 10 yrs came with complaints of palpitations associated with anxiety and shortness of breath grade III/IV occurring intermittently, lasting for 5-10 mins and not associated with syncope or sweating. He had an attack of MI two months ago and has anxiety issues resulting in disturbed sleep.

PROVISIONAL DIAGNOSIS

A 47 yr old male k/c/o hypertension and diabetes with palpitations due to  

• CARDIAC CAUSES
• Myocardial infarction
• Cardiomyopathy
• Ventricular tachycardia
• NONCARDIAC CAUSES
• Anemia
• Electrolyte disturbances
• Hyperthyroidism
• Hypoglycemia
• Pheochromocytoma

Investigations

Chest X-ray

ECG

Additional investigations  ( awaiting the results)

2D-ECHO -

THYROID PROFILE - T4, TSH ordered, awaiting the results.

CBP (COMPLETE BLOOD PICTURE)

Hb%

Fasting blood sugar, HbA1c

Plasma metanephrines or 24 hr urinary metanephrines