A 50 year old female with palpitations
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I have been given this case to solve in an attempt to understand the topic of " patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with diagnosis and treatment plan.
CASE PRESENTATION
A 50 year old female resident of Narketpally municipality worker by occupation came to the general medicine OPD (15-12-2022) with the chief complaints of
• palpitations since 3 days
HISTORY OF PRESENTING ILLNESS
Patient was apparently asymptomatic 3 days ago and then she developed palpitations which is sudden in onset,continous,even at rest which aggravates on walking and no relieving factors.
No history of shortness of breath
No history of chest pain,dizziness
No history of orthopnea, PND
No history of cough,abdominal distension,pedal edema
PAST HISTORY
Not a known case of hypertension, diabetes mellitus, CVD,asthma,epilepsy.
FAMILY HISTORY
no relevant family history
PERSONAL HISTORY
Diet- mixed
Appetite - decreased
Sleep- regular
Bladder- regular
Bowel- constipation (passes stools once in 2-3days)
Addictions- consumes toody occasionally (1litre)
GENERAL EXAMINATION
patient is conscious, coherent, cooperative and well oriented towards time,place,person and malnourished.
Pallor - present
Right eye
left eye
No icterus,cyanosis, clubbing,lymphadenopathy
Temperature - afebrile
Blood pressure - 110/90nn of Hg
Pulse rate- 96bpm
Respiratory rate-18cpm
CVS EXAMINATION
INSPECTION
Shape of chest - bilaterally symmetrical
No visible pulsations
Keloid noticed over the left breast
No sinuses
PALPATION
No thrills,parasternal heaves
AUSCULTATION
S1, S2 heard
No murmurs heard
RESPIRATORY SYSTEM
Shape of chest - bilateraly symmetrically
Trachea position- central
Bilaterally air entry - present
Normal vesicular breath sounds are heard.
PER ABDOMEN
Soft,non tender,no organomegaly
CNS
No focal neurological deficit
INVESTIGATIONS
RBS - 103mg/dl
Uric acid -5.4mg%
Serum creatinine- 0.8mg/dl
Blood urea - 32mg/dl
2D ECHO 14-12-2022
15-12-2022 &16-12-2022
ECG ON 16-12-2022
DIAGNOSIS
Atrial fibrillation
fast ventricular rate
Heart failure with preserved ejection fraction
Chronic AF?
TREATMENT
T.Met xp50mg PO/OD
T.Ecosporin AV
hourly BP and heart rate monitoring
DAY 3
S
palpitations decreased
O
Patient is conscious, coherent,cooperative
Bp: 110/70 mm of Hg
PR:74bpm
RR:18cpm
Temperature: afebrile
RBS: 105mg/dl
CVS:S1 S2 heard
BAE:present
CVS: no focal neurological deficit
Per abdomen: no tender,no organomegaly
A
Atrial fibrillation with fast ventricular rate (resolved)
Heart failure with preserved ejection fraction
Chronic AF?(reverted to sinus rhythm)
P
T.Met xp50mg PO/OD
T.Ecosporin AV
hourly BP and heart rate monitoring
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