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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
-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
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
Abdominal system
- Normal oral mucosa.
- Abdomen distended , umbilicus central
- No scars, sinuses, or any engorged veins.
- Hernial orifices intact
- Tenderness or guarding absent
- No enlargement of liver, kidneys, or spleen
- No ascites
- Bowel sounds were normal
- PR not done.
- Gait is normal.
- No muscle or soft tissue changes.
- No bone or joint deformities.
- No limitation of movements.
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
THYROID PROFILE - T4, TSH ordered, awaiting the results.
CBP (COMPLETE BLOOD PICTURE)
Hb%
Fasting blood sugar, HbA1c
Plasma metanephrines or 24 hr urinary metanephrines
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