LONG CASE
HALL TICKET NO. 1601006149
This is an online E log book to discuss our patient's de-identified health data shared after taking his/her/guardian's signed informed consent. Here we discuss our individual patient's problems through a series of inputs available global online community of experts with the aim to solve the patient's clinical problems with the collective current best evidence based inputs. This E-log book also reflects my patient centred online learning portfolio and your valuable inputs in the comments section.
A 70 YEAR OLD MAN WITH RECURRENT EPISODES OF SYNCOPAL ATTACKS
A 70 year old man, who is a Weaver from Nakrekal, was rushed to the ER at Kamineni Institute of Medical Sciences, Narketpally on 23/04/2021, following an episode of loss of consciousness for 1 minute that very same evening.
HISTORY OF PRESENTING ILLNESS:
- Patient was apparently symptomatic earlier yesterday afternoon, then at 04:00 PM, when he was weaving clothes he had sudden onset of giddiness as he pushed his table aside to stand up.
- Giddiness was sudden in onset and associated with profuse sweating, blurring of vision and palpitations.
- He had transient loss of consciousness for one minute. Patient says he remembers the start of the episode but doesn't recall anything that happened thereafter.
- He had post syncopal generalised weakness and confusion.
- He had three more episodes. One at 10:00 PM on 23rd April, the other two at 12:00 AM and 6:30 AM on 24th April for which was present in the hospital. The last episode lasted for longer and the patient had post syncopal weakness for half hour.
- Not associated with any chest pain, blackouts, photophobia, phonophobia, involuntary movements, involuntary micturition, froth from mouth, tongue bite, uprolling of eyes.
- No history of trauma or lifting of heavy weights.
- No postural drop of blood pressure, no history of seizures and motor/sensory deficits.
- No history of fever, neck pain, ear pain, discharge or tinnitus.
PAST HISTORY:
- No similar complaints in the past.
- He is a known case of Diabetes Mellitus-2 since 15 years and Hypertension since 10 years.
- No history of Thyroid disorders, Epilepsy, CVD, Bronchial asthma, TB.
TREATMENT HISTORY:
- Patient has been on medication for Diabetes Mellitus-2 since 15 years- Glimiperide OD (2 PM)
- For Hypertension- Telmisartan OD
- Atorvastatin + Aspirin (75 mg)
FAMILY HISTORY:
Not significant
PERSONAL HISTORY:
- He consumes a Mixed diet.
- His appetite is normal.
- His sleep is adequate and undisturbed.
- His bowel and bladder movements are regular.
- Occasionally consumes alcohol; doesn't smoke.
- No known allergies.
PHYSICAL EXAMINATION (after taking informed consent from the patient)
GENERAL EXAMINATION:
- The patient is conscious, coherent and cooperative, sitting comfortably on the bed.
- He is well oriented to time, place and person.
- He is moderately built and moderately nourished.
- No sign of Pallor, Icterus, Cyanosis, Clubbing, Lymphadenopathy and Edema.
Vitals:
- The patient is afebrile.
- Pulse rate: 84 beats per minute, regular, normal in volume and character. There is no radio-radial or radio-femoral delay. The condition of the arterial wall is normal.
- Respiration: 18 cycles per minute
- Blood Pressure:
- Left arm: 140/80 mm Hg
- Right arm: 160/80 mm Hg
- JVP is normal and not elevated.
SYSTEMIC EXAMINATION:
CARDIO VASCULAR:
- On inspection, his chest wall is normal and symmetrical. JVP is normal not elevated
- On palpation, carotid pulse felt on both sides; Apex beat felt at left fifth Intercostal space medial to mid clavicular line.
- On auscultation, S1 S2 heard, no cardiac murmurs.
RESPIRATORY SYSTEM:
- On inspection, chest moves evenly with respiration. No use of accessory muscles of respiration, no intercostal retractions. Trachea is central with no deviation.
- Inspection findings are confirmed on palpation.
- On percussion, lungs are resonant.
- On auscultation, vesicular breath sounds heard; bilateral air entry is present. No dyspnea/wheeze.
ABDOMINAL EXAMINATION:
- On inspection, all abdominal quadrants are moving evenly with respiration. Not visibly distended, no visible organomegaly. No engorged veins or sinuses.
- On palpation, inspection findings are confirmed. Liver is not enlarged, non tender. Spleen is not palpable.
- On auscultation, no bruits are heard. Bowel sounds are normal.
- On percussion, there is no shifting dullness.
CENTRAL NERVOUS SYSTEM EXAMINATION:
- Patient is conscious.
- His speech is normal.
- No signs of meningeal irritation. No nystagmus.
- Motor system, Sensory system and Cranial Nerves- Normal
PROVISIONAL DIAGNOSIS:
SYNCOPE
- Cardiac syncope- arrythmias
- Postural hypotension
- due to patient being on Antihypertensives.
Comments
Post a Comment